North East Scotland

The account of the complaint provided by Mrs G was that in February 2001 her son was put on the waiting list for orthodontic treatment. Mrs G subsequently learned that the waiting time for this treatment is approximately three and a half years. Mrs G complained about the waiting time; she asked for an explanation or remedy for the situation. The Chief Executive of the Trust replied apologising for the lengthy waiting time and acknowledged that this was unsatisfactory. Mrs G sought an independent review of her complaint. The Convener refused her request on the ground that this was primarily a resource issue for which a reasonable explanation had been given.

The complainant, Mr J, put it that the Trust took an unreasonable length of time to diagnose his wife's bowel cancer resulting in her death.

The account of the complaint provided by Mr R junior was that on 22 March 2001 his father Mr R, aged 90, was admitted to Glasgow Royal Infirmary (the hospital) with a history of vomiting and diarrhoea. This resolved and he was discharged on 30 March. On 1 April Mr R was readmitted (to a different ward of the hospital) with diarrhoea and dehydration. He was diagnosed as having a clinical infection caused by Clostridium difficile but attempts to control this by the use of metronidazole (Flagyl - an antibiotic) failed. It was decided to change his treatment to vancomycin. This was prescribed on 20 April and Mr R junior was told it had to be made up specially by the hospital pharmacy which caused a delay. Mr R died during the early morning on 21 April.

The account of the complaint provided by Mr R junior was that on 22 March 2001 his father Mr R, aged 90, was admitted to Glasgow Royal Infirmary (the hospital) with a history of vomiting and diarrhoea. This resolved and he was discharged on 30 March. On 1 April Mr R was readmitted (to a different ward of the hospital) with diarrhoea and dehydration. He was diagnosed as having a clinical infection caused by Clostridium difficile but attempts to control this by the use of metronidazole (Flagyl - an antibiotic) failed. It was decided to change his treatment to vancomycin. This was prescribed on 20 April and Mr R junior was told it had to be made up specially by the hospital pharmacy which caused a delay. Mr R died during the early morning on 21 April.

South Glasgow University Hospitals NHS Trust

Summary

Ms C’s daughter (Miss A) has complex medical needs.  In 2011, the council assessed her as requiring 42 nights respite care each year but so far, this had not been provided. As her own health was suffering, and threatening to compromise the care she could give Miss A, Ms C made a formal complaint to the council about their failure to provide Miss A with the respite care she needed.

The council acknowledged that despite their efforts, they had been unable to meet Miss A’s requirements; they said that the resources needed in terms of the availability of a suitable carer, and the specialist knowledge and training required, were in short supply. They had approached a children’s hospice; a local charity with residential care facilities and put funding in place to provide assistance from Ms C’s mother.  The council said that although they had had no success, it remained their priority to provide Miss A with the respite care she needed.

We took independent social work advice and found that Miss A’s complex needs made it extremely challenging to provide an appropriate service for her.  The council had looked at a number of options which, for reasons outwith their control, had not proved possible. However, with the passage of time, there should have been greater consideration of Miss A’s circumstances and those of her family, a greater recording of the action taken by the council and a more creative and imaginative approach in order to show that they had done everything in their power to satisfy Miss A’s unmet respite care needs. We upheld the complaint.

Redress and Recommendations
The Ombudsman's recommendations are set out below:

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

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

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

Summary

Miss C complained about the care and treatment her late brother (Mr A) received from Tayside NHS Board (the Board).  Mr A had type 1 diabetes with recurrent episodes of hypoglycaemia (when the level of sugar (glucose) in the blood falls below a set point) and a learning disability.  Mr A, who had been a patient with the Board’s diabetes service since he was a teenager, died unexpectedly aged 38 years.

Miss C complained there was a failure by the Board to appropriately assess and treat Mr A and to take account of how his learning disability affected his ability to manage his diabetes care.

We took independent advice from a consultant diabetologist.

Our investigation found that the management of Mr A’s type 1 diabetes, given his learning disability, would have been challenging.  However, in view of Mr A’s recurrent often severe hypoglycaemic episodes and his apparent lack of awareness of his condition and how to manage it effectively, the Board should have focused on the management of his hypoglycaemia, listened to the concerns of Mr A’s family and carried out a full assessment of Mr A’s awareness of hypoglycaemia.  The Board did not provide us with evidence that they did so.

We found that consideration should have been given to investigating whether there were any other possible underlying additional contributing conditions for Mr A’s recurrent hypoglycaemic episodes as recommended in national guidelines and the recognised associations with other autoimmune diseases, given his family history of autoimmune disease. 

While there had been attempts by the Board to change Mr A’s insulin regime in the years prior to his death, which were unsuccessful, there was no evidence that consideration was given to trying other treatment or of a referral to other centres with more expertise in severe hypoglycaemia to try and address and mitigate against Mr A’s recurrent severe hypoglycaemia. 

Although it could not be definitely said that Mr A’s death was as a consequence of a severe hypoglycaemic episode, it was possible given the circumstances of his unexpected death and as recurrent severe hypoglycaemia has been strongly linked as the potential basis for sudden death in persons with type 1 diabetes.

We considered the lack of action by the Board in their management of Mr A’s diabetes represented a serious failure in his care and treatment and we upheld the complaint.

While we acknowledged and welcomed the remedial action the Board has taken on the need to better support people with diabetes and who have a learning disability, we considered this did not go far enough to address the root causes of the issues raised in this case.  In particular, we were of the view the Board had not addressed the underlying clinical issues concerning the assessment and management of patients with type 1 diabetes and recurrent severe hypoglycaemia.  We made a number of recommendations to address the failings in this case.

Redress and Recommendations
The Ombudsman's recommendations are set out below:

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

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

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

Summary

Ms C complained about the care and treatment provided to her late father, Mr A, by Greater Glasgow and Clyde NHS Board (the Board) in the Enhanced Recovery Area at Glasgow Royal Infirmary (the Hospital).  Mr A was admitted to the Hospital with a history of recent weight loss and abdominal pain.  He had a laparotomy (an incision in the abdomen), which showed a lump in his colon.

Mr A underwent a primary anastomosis (where sections of the intestine are reconnected following the removal of diseased tissue).  After the operation, he was admitted to the High Dependency Unit (HDU).  Ms C has stated that the nursing care Mr A received there was excellent and that the family were welcomed to actively participate in his recovery.  She also told us that her father was improving and was mobile in the hours prior to his transfer out of the HDU.  He was then transferred to the Enhanced Recovery Area in the Hospital.  Ms C complained to us about both the medical treatment and the nursing care her father received in the Enhanced Recovery Area when his condition deteriorated.  Following transfer back to HDU, Mr A had further surgery, however, he died there several days later.

We took independent advice from a consultant general surgeon (Adviser 1) and a general nursing adviser (Adviser 2).  In relation to Ms C’s complaint that the Board did not provide reasonable medical treatment to Mr A in the Enhanced Recovery Area, we found that there were a number of failings.  In summary:

• communication with Ms C’s family had been unreasonable and staff had failed to act on their concerns;
• had Mr A been assessed and examined proactively by an experienced doctor earlier, it was likely that they would have recognised his deterioration and escalated his care sooner. Had this happened, there would have been a greater chance of survival;
• a CT scan should also have been carried out sooner and this would have alerted staff to the anastomosis leaking and gross abdominal infection;
• there were case note entries from a variety of junior doctors, but little documented evidence of Consultant involvement;
• there was delay in providing a dietician assessment;
• the majority of medical interventions appeared to be reactive rather than proactive. 

In view of these failings, we upheld Ms C’s complaint that the Board did not provide reasonable medical treatment to Mr A.

Ms C also complained that the Board did not provide reasonable nursing care to Mr A in the Enhanced Recovery Area.  We found that the actions of nursing staff in relation to Mr A’s transfer to the Enhanced Recovery Area had been reasonable.  This included their actions in relation to mobilising Mr A and in maintaining his fluid and nutritional intake.  However, we also found that the monitoring and observation of Mr A had not been reasonable and was not carried out in line with the relevant guidance.  In view of this, we upheld Ms C’s complaint that the Board did not provide reasonable nursing care to Mr A in the Enhanced Recovery Area.

Redress and Recommendations
The Ombudsman's recommendations are set out below:

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

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

Feedback

Points to note

The Board should note Adviser 2’s comment in relation to the entry in the nursing records that the family were, ‘to be encouraged not to visit at mealtimes.’

Complaints handling

The Board are encouraged to reflect on their own handling of the complaint and why their investigation did not identify the good and poor practice in the provision of care.

Summary

Mrs C complained about the care and treatment that staff at Queen Elizabeth University Hospital (the Hospital) provided to her late husband, Mr A.

Mr A previously received hip replacement surgery at the Hospital and was discharged.  He was given clexane on the ward and aspirin on discharge as prophylaxis (preventative medication) to reduce the risk of venous thromboembolism (VTE - blood clots that start in the vein), including pulmonary embolism (a sudden blockage in a major artery).

Approximately three weeks later, Mr A suffered a sudden bleeding from his bowels.  He was re-admitted to the Hospital with a suspected upper-gastrointestinal bleed.  Staff carried out an endoscopy (a procedure to look inside the oesophagus, stomach and first part of the small intestine) and took blood tests.  A sigmoidoscopy (a procedure that involves looking inside the large intestine) could not be carried out.  The next evening, Mr A suffered a sudden collapse and died as a result of a cardiac arrest caused by a pulmonary embolism.

Mrs C raised concerns about the medical and nursing care provided to Mr A, including the investigations carried out, a decision not to give a blood transfusion, monitoring, and the events surrounding his death.

We took independent advice from three clinical specialists: an orthopaedic surgeon, a consultant in acute medicine and a nurse.

As the cause of death was pulmonary embolism, we investigated the VTE prophylaxis given to Mr A during his first admission to the Hospital.  We found VTE prophylaxis in the Hospital was appropriate, but discharge on aspirin was not supported by national guidance and the Board’s own guidelines were not followed.  We noted that there is no completely effective way of preventing pulmonary embolism; however, providing appropriate medication could have reduced the risk to Mr A.  We were unable to rule out the possibility that this failing may have contributed to Mr A’s death.  We also found there was an apparent lack of consultant involvement in Mr A’s pre-operative management.

Our investigation found medical care during the second admission was reasonable.  We noted this was a complex admission, but the correct investigations were carried out and it was appropriate not to give a blood transfusion.  We found medical staff did not miss any warning signs of the pulmonary embolism, noting that pulmonary embolism can occur suddenly, without warning, and with no obvious signs.

We found that nursing care during the second admission was unreasonable.  In particular, there was a failure to record repeat observations for the evening Mr A died.  We also noted, as the Board acknowledged, the difficult circumstances surrounding Mr A’s death could have been handled more sensitively by some staff.

We upheld Mrs C’s complaints and made a number of recommendations to address the issues identified.

Redress and Recommendations
The Ombudsman's recommendations are set out below:

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

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

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

Feedback

Communication

I urge the Board to reflect on how they communicate with families, particularly in sensitive and difficult situations such as the death of loved ones.  In doing so, it would be appropriate to consider what use is made of resources such as death and dying teaching and written resources such as the Scottish Government’s publication ‘What to do after a death’, to support the families of patients at such difficult times.

Summary

Ms C complained on behalf of her nephew (Mr A) about the care and treatment Mr A received from the Greater Glasgow and Clyde NHS Board (Board 1).  Ms C’s complaint concerned the delays in treatment for Mr A’s dural arteriovenous fistula (DAVF – where there are rarer, abnormal connections between arteries and veins in a protective membrane on the outer layer of the brain and spine, called the dura. Symptoms can include an unusual ringing or humming in the ears, particularly when the DAVF is near the ear, and some patients can hear a pulsating noise caused by the blood flow through the fistula) and the poor communication with him about this.  The original complaint we received concerned the treatment of Mr A’s arteriovenous malformation in the brain (AVM - where a tangle of blood vessels in the brain or on its surface bypasses normal brain tissue and directly diverts blood from the arteries to the veins). During the course of our investigation, it was identified that there were different types of AVM and that Mr A had one type, known as DAVF.

We obtained independent advice on the case from a consultant neurosurgeon, a consultant interventional neuroradiologist and a consultant in public health medicine.

We found that that Board 1 unreasonably failed to provide Mr A with treatment for his DAVF and we upheld this part of the complaint. We also found that, having advised Mr A that a hospital in another board’s area was willing to provide treatment for his condition, Board 1 then failed to make arrangements for this within a reasonable time and we upheld this part of the complaint. We found that Board 1 failed to keep Mr A updated on his proposed treatment and that Mr A and his family had to contact Board 1 repeatedly to find out what was happening and that Board 1 also failed to respond to Mr A’s email detailing his concerns about Board 1’s response to his complaint. We, therefore, upheld this part of the complaint. We made a number of recommendations to address the failings in this case.

Redress and Recommendations
The Ombudsman's recommendations are set out below:

What we are asking Board 1 to do for Ms C and Mr A:

We are asking Board 1 to improve the way they do things:

Feedback

Response to SPSO investigation

Board 1 failed to respond to my enquiries by the deadlines set and failed to provide full and complete responses, which delayed our investigation of Ms C’s complaint.