North East Scotland

Summary

Ms C complained about the care and treatment she received when she presented to the Neurology Department (the Department) at Aberdeen Royal Infirmary following a referral from an out-of-hours GP.  Two days following her first presentation to the Department, Ms C was diagnosed with cauda equina syndrome (a rare and serious neurological condition that affects the bundle of nerves (cauda equina) at the base of the spine).  Ms C raised concern that there had been a delay in carrying out an MRI scan and, following this, performing surgery for her condition.  Ms C felt that if her condition had been diagnosed and treated sooner, her chance of making a more complete recovery would have increased.

We took independent advice from a consultant neurosurgeon, which we accepted.

We found that there was an unreasonable delay in providing Ms C with appropriate treatment.  We noted that, under the clinical guidance in place at the time, the Board should have carried out an emergency MRI scan and then performed emergency surgery during Ms C's first admission.  We considered that it was unreasonable that Ms C did not receive an MRI scan and surgery until she returned to the Department two days later.  We concluded that, if the surgery had been carried out when it should have been, then it is more likely that Ms C would have maintained better urological and sexual function.  However, we were unable to say that Ms C would have recovered to normal function.  We also found failings with the documentation of the assessments carried out in the Department during both admissions and we were unable to conclude that the assessments were reasonable.

Ms C was also dissatisfied with the Board's response to her complaint.  We found that the Board's response had referred to a timescale for providing surgery that was not relevant in this case.  We considered that the Board should have considered their response more carefully and referred to relevant guidelines.  We considered that the Board failed to establish all of the facts relevant to the points Ms C raised.  We concluded that the Board's response to Ms C's complaint was unreasonable. 

We upheld Ms C's two complaints and made a number of recommendations to address the issues identified. The Board have accepted these recommendations and we will follow-up on these recommendations.  The Board are asked to inform us of the steps that have been taken to implement these recommendations by the dates specified. We will expect evidence (including supporting documentation) that appropriate action has been taken before we can confirm 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 Ms C:

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

Feedback
Response to SPSO investigation
The Board should ensure that all relevant evidence is provided to my office when this is first requested.  In this case, the Board's failure to do this contributed to delays in the investigation.

Points to note on best practice
In view of the record-keeping and complaints handling issues identified, the Board should consider sharing this report more widely with staff in other services to highlight the importance of these matters.

Summary
Mrs C complained about the care and treatment she received from Queen Elizabeth University Hospital Glasgow (the hospital).  Mrs C was concerned about delays in the time taken for her to receive spinal surgery to address her medical condition (incomplete cauda equina syndrome).  In addition, Mrs C complained about the level of care provided during her two admissions by physiotherapy and nursing staff.  Mrs C also raised concerns about the aftercare arrangements made at the time of her discharge from the hospital.

We took independent advice from three clinical specialists:  a consultant neurosurgeon, a physiotherapist and a nurse.

We found that the board failed to provide neurosurgery to Mrs C within a reasonable time.  We noted that there had been unexpected repair works at the hospital that impacted on theatre availability; however, there is clear guidance on the need for surgery to be performed on an emergency basis in cases of incomplete cauda equina syndrome to minimise the risks associated with this condition.  In these circumstances, we considered it was unreasonable for the board not to have provided the surgery, or arranged for this to take place at an alternative hospital site.  We considered that it was likely that the delay would have impacted on Mrs C's poor outcome following the surgery.  Our investigation also highlighted that there was no evidence of communication with Mrs C about the risks of the delays while she was on the neurosurgery ward, and that documentation in the relevant medical records was of a very poor standard.

Our investigation identified failings in the care and treatment provided to Mrs C during her admissions.  We found that Mrs C's care while in hospital and on discharge did not appear to have been planned in a co-ordinated and multi-disciplinary way.  We found that Mrs C did not receive an adequate level of physiotherapy care.  We also had concerns about the level of continence care provided to Mrs C, the management of her pain and wound care based on the evidence in the nursing records.

We found that there were failings in discharge planning and aftercare arrangements for Mrs C.  We considered this was not planned in a co-ordinated and multi-disciplinary way.  Our investigation also found there was inadequate patient information provided to Mrs C on discharge, and referrals for aftercare were not made.  We noted that this likely contributed to Mrs C's difficult and distressing experience returning to her home.

We upheld Mrs C's three complaints and made a number of recommendations to address the issues identified.  The board have accepted these recommendations and we will follow-up on these recommendations.  The board are asked to inform us of the steps that have been taken to implement these recommendations by the dates specified.  We will expect evidence (including supporting documentation) that appropriate action has been taken before we can confirm 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 Mrs C:

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

Feedback
Complaints handling
I agree with Adviser 3's comment about the Board's handling of this complaint.  The Board did not investigate this complaint in a sufficiently detailed and analytical manner.  They appeared defensive of, and failed to take account of the gaps in, nursing practice as evidenced in the nursing notes.  While printed nursing records are lengthy, and consideration has been given to how they might facilitate assessment and care planning, it was nonetheless difficult (on the basis of this investigation) to understand the priorities for Mrs C's care. This must cause difficulty in personalising the care to meet individual patient need and for nurses, working different shifts, to be clear about the care plan.

Points to note on best practice
In line with the views of Adviser 2, I would ask the Board to consider the following points about delivering best practice in the care of patients presenting with cauda equina syndrome:

• patient representation on the Cauda Equina Forum;
• patient information developed for people who are at risk of developing cauda equina syndrome and for those with incomplete cauda equina syndrome for issue at the time of diagnosis;
• to ensure that the diagnosis of cauda equina syndrome is recorded, explained to the patient and communicated clearly across the multi-disciplinary team;
• training arranged for all members of the clinical team to ensure that; the diagnosis of cauda equina syndrome, the prognosis and the importance of personalised co-ordinated postoperative management are understood;
• a clear pathway to urology;
• a clear pathway to pain services; and
• a governance reporting system for cases who have poor post-operative outcomes related to cauda equina syndrome.

Points to note on the development of the information leaflet
The Board is asked to consider the following suggestions from Adviser 2 for further improvement:

• page 2:  It is important to treat cauda equina syndrome as an emergency not urgently;
• page 3:  the symptoms of cauda equina syndrome can also occur gradually, often related to spinal stenosis;
• page 4:  women may also have sexual dysfunction related to vaginal numbness;
• page 7:  links to patient support groups such as; www.caudaequina.org,  www.ihavecaudaequina.com or www.caudaequinauk.com might be included; and
• the inclusion of guidance on when and where to seek help should symptoms deteriorate.

Summary
Ms C complained about the treatment provided to her late mother (Mrs A).  Mrs A was 53 years old when she attended at Aberdeen Royal Infirmary (the hospital) with lower abdominal pain and urinary frequency.  She was discharged with plans for urgent follow-up.  Before this took place, Mrs A was re-admitted via the emergency department.  She was found to be suffering from cancer and procedures to insert plastic tubes into her kidneys to drain urine were necessary.  The procedure, called nephrostomy, is carried out when the tube linking the kidney to the bladder has become blocked.  After the nephrostomies were carried out, Mrs A later began to show signs of infection.  Although antibiotic treatment was started, Mrs A developed sepsis (a severe complication of infection) and died.

Ms C complained that Mrs A had not been prescribed prophylactic antibiotics (antibiotics given as a precaution to prevent, rather than treat, an infection) prior to the nephrostomies.  The board initially responded that there was no requirement to prescribed these and Ms C brought her concerns to this office for investigation.  A short time later, the board advised us that a hospital policy recommending the use of prophylactic antibiotics had been identified.  We suspended our investigation to allow the board to address this matter and a number of further issues Ms C raised.  After the board issued their final response, Ms C brought the complaint back to this office and we restarted our investigation.

We took advice from a consultant urologist.  We found that there had been a failure to follow the hospital policy on prescription of prophylactic antibiotics for Mrs A.  We established that Mrs A had a poor prognosis due to the extent of her cancer.  While prescribing prophylactic antibiotics may­ have prevented her from developing sepsis, it was impossible to definitively determine the effect they would have had.

Although the board latterly acknowledged its policy had not been followed, no apology was offered to Ms C for either the failing itself or for the fact its initial complaint response was inaccurate.  We upheld Ms C's complaint 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 Ms C:

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

Feedback
Complaints handling
Due to new issues being raised by Ms C, this investigation was suspended to allow the Board to respond.  By this time, the Board had recognised that there was, in fact, a local recommendation to prescribe prophylactic antibiotics for patients like Mrs A.  This represented an opportunity for the Board to acknowledge that its original response was inaccurate and apologise.  More effective handling of this complaint could have resolved the matter for Ms C at an earlier stage without the need for this further investigation.  The Board should reflect on this.

Summary
Mr C complained about the care and treatment provided to his late wife (Mrs A).  Mrs A was diagnosed with bladder cancer in April 2015 and Mr C complained that both before and after the diagnosis there were delays in providing necessary appointments.  Mr C also complained that there were unreasonable delays in the treatment of Mrs A's cancer after she had cardiac surgery, and that there were failings in communication between specialists treating her.

We took advice from a consultant urologist.  With regards to delays in appointments, we found that there was an unreasonable delay between the results of a biopsy being taken and a subsequent resection.  We also found that there was an unreasonable delay from the time of diagnosis to the time that Mrs A discussed definitive management with a surgeon.  We considered these delays to be unreasonable.  We upheld this aspect of Mr C's complaint.

We also found that there was a delay in Mrs A being provided with treatment for her bladder cancer.  We identified a failure of the urology service to act upon a letter which stated that Mrs A would be suitable to go ahead with treatment for her bladder cancer in a months' time.  We further found that the possibility of Mrs A's condition deteriorating, and her treatment options, were not fully discussed with her, and that there was a delay in Mrs A being offered palliative radiotherapy.  We determined that there were multiple failings in communication between specialists treating Mrs A regarding her condition and treatment.

Mr C also complained about the board's handling of his complaint, specifically that they did not address all of the issues which he had raised.  We considered that the board had failed to address some important questions Mr C had asked, and therefore we upheld this aspect of Mr C's complaint.

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

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

Evidence of action already taken
Greater Glasgow and Clyde NHS Board - Acute Services Division 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 she received from Grampian NHS Board (the board).  As Ms C was experiencing post-menopausal bleeding, her GP urgently referred her to the gynaecology service of Aberdeen Royal Infirmary.

Ms C's referral was downgraded from urgent to routine by the gynaecology service.  She was offered an appointment six weeks after her GP referral.  Her GP contacted the gynaecology service on two occasions to request an earlier appointment but was told it was unnecessary for Ms C to be seen any sooner.  When Ms C contacted the gynaecology service, they agreed to bring her appointment forward by a week.  Given her concerns, Ms C was told that a consultant gynaecologist would look at her ultrasound scan report.  Ms C received a phone call from a non-clinical staff member reassuring her that she did not need an urgent appointment.

When Ms C attended her appointment at the gynaecology service, an endometrial biopsy was carried out.  When the results were issued, Ms C was diagnosed with endometrial cancer.

During our investigation, we took independent advice from a consultant gynaecologist and from a consultant obstetrician and gynaecologist.  We found that Ms C's referral should not have been downgraded to routine and she should have been seen by the gynaecology service within two weeks of her GP referral.  We found that the target for the treatment of Ms C's cancer was missed by 19 days.  We found that Ms C should not have been given reassurance about the findings of her ultrasound scan report as they could have indicated cancer.  We also found that this reassurance should not have been given to Ms C by a non-clinical staff member.  We upheld Ms C's complaint.

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:

Summary
Mrs C complained to us about the care and treatment provided to her late son, (Baby A), at the Aberdeen Royal Children's Hospital.  Baby A had been fitted with a shunt (a medical device that relieves pressure on the brain by draining excess fluid into the abdominal cavity) shortly after he was born.  Mrs C complained that when he was admitted to the hospital several months later, there were multiple failings in care and treatment.  Baby A passed away in a specialist paediatric neurosurgery centre under another health board a few days after his admission to the hospital.

During our investigation, we took independent advice from a paediatrician, a neurosurgeon, and an anaesthetist.  We found that although the board's internal investigation had identified some issues in Baby A's care and treatment, they had not addressed the important issues with the episode of care.  Our investigation determined that there was a lack of clarity regarding the roles of each medical team, and that there was a lack of communication between consultants when Baby A's condition was not improving.  We also found that the neurosurgical team had not kept reasonable records, nor had they appropriately assessed Baby A before and after operations.  We identified significant delays in Baby A being reviewed after he underwent operations, and a delay in clinicians contacting the specialist centre for advice on the management of Baby A.  Finally, we considered there to have been a lack of communication from the neurosurgical team and Baby A's parents.  Given the multiple failings identified by our investigation, we upheld this aspect of Mrs C's complaint.

Mrs C further complained to us that after Baby A's death, the board did not contact her or communicate with her until she submitted her complaint.  The board accepted that this was unacceptable, and we upheld this aspect of Mrs C's complaint.

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:

Summary
Mr C complained on behalf of his sister (Miss A) who had amongst other things profound learning difficulties, type 2 diabetes and was blind.  He said that after falling out of bed and hurting her neck on 12 December 2015, she attended the Emergency Department (ED) of Glasgow Royal infirmary.  Although the board maintained that Miss A had been treated reasonably, Mr C said that staff did not take into account her serious disabilities when examining and treating her and she was discharged home.  Miss A's condition deteriorated and she returned to the ED where she was later given an x-ray and CT scan which showed fractures in her neck.  She was admitted to the National Spinal Injuries Unit.

We took independent advice from a consultant in emergency medicine and from a registered nurse.  We found that despite the fact that Miss A had serious and profound learning difficulties which were detailed in documentation that accompanied her to the ED, these were not properly taken into account, a senior opinion was not obtained nor were available objective assessment tools used.  Mr C's opinions were not sought to establish whether he could input into the findings of her examination.  We upheld the complaints.

Redress and recommendations
The Ombudsman recommends that the Board:

• make a formal apology to Mr C and Miss A for the shortcomings identified;
• staff involved in Miss A's care on the day concerned should be made aware of the content of this report to allow them the opportunity to reflect and also consider it at their next formal appraisal;
• apologise to Miss A (copied to Mr C) that when communicating with her, staff failed to take her learning difficulties into account;
• apologise to Mr C for not reverting to him for his assistance in this matter; and
• review their advice to staff members about treating people with disabilities to establish whether or not it is currently fit for purpose.  If it is not, they should provide updated advice and guidance.

Summary
Mrs C complained about the care and treatment given to her young son (Master A) when he attended a hospital Emergency Department (ED) over a period of two days after he suffered a head injury at nursery.  Master A has hydrocephalus and had had a shunt fitted a few months after he was born to relieve the pressure caused by fluid accumulation.  Because of this, Mrs C said that as well as the usual checks and examination, he should also have been given a precautionary CT scan.  He was not and was discharged home.

A month later, Master A and his family went abroad on holiday and he became very ill and was taken to hospital.  A CT scan taken there showed that his shunt had become dislodged and he had suffered a bleed.  He remained in hospital for four days before being returned home.

Mrs A complained to the board who took the view that the care and treatment given to Master A on the two occasions he attended the ED was reasonable.  Our investigation showed that Master A's examination in the ED had been good, specific and relevant.  However, as he had attended again for the same problem within a short time, caution needed to be taken; on the second occasion his head injury should have been discussed with a senior member of staff and as there was reason to question a shunt malfunction, staff should have had a low threshold of suspicion and considered a CT head scan.  Alternatively, as his parents felt that Master A's condition had not returned to normal, he should at least have been admitted for observation.  For these reasons, we upheld the complaint.

Redress and recommendations
The Ombudsman recommends that the Board:

• make Mrs C a formal apology recognising the identified shortcomings identified in this report; and
• ensure that the clinical staff involved in Master A's case make themselves fully aware of the relevant Scottish Intercollegiate Guidelines Network guidance ('Early management of children with a head injury', May 2009) to ensure that the same situation does not recur.

Summary
Mr C complained to us that the board had failed to provide his wife (Ms C) with appropriate clinical treatment following a GP referral to Perth Royal Infirmary for a suspected brain aneurysm.  Ms C had been referred to the hospital by a GP after becoming unwell.  In the referral letter, the GP referred to, amongst other things, a suspected subarachnoid haemorrhage (an uncommon type of stroke caused by bleeding on the surface of the brain).  Ms C had reported sudden onset of pain in her head and neck with some visual disturbance.  She was admitted directly to the acute medical unit in the hospital where she was medically assessed by a specialist trainee doctor.  She was then reviewed by a consultant physician.  She was subsequently discharged home with the problem felt to be musculoskeletal.

Ms C attended her GP on several occasions over the next few weeks.  She then collapsed at home and was taken to the intensive care unit with signs of acute subdural haematoma (a serious condition where blood collects between the skull and the surface of the brain).  Further treatment was not deemed appropriate and Ms C died in the hospital two days later.

We took independent advice on Mr C's complaint from a consultant physician.  The adviser noted that there were sufficient features to suggest that Ms C had a thunderclap headache and that a CT scan should have been performed at that time.  If this was negative, a lumbar puncture (a medical procedure where a needle is inserted into the lower part of the spine to test for conditions affecting the brain, spinal cord or other parts of the nervous system) should have then been performed and, if positive for subarachnoid haemorrhage, a neurological opinion would have been essential at that point.

We found that it was unreasonable that Ms C had been diagnosed with musculoskeletal neck pain.  The adviser said that a patient with no previous significant headache history who presents with sudden severe neck and occipital pain (pain at the back of the head) should be investigated as a thunderclap headache.  We also found that Ms C had not been monitored appropriately in the acute medical unit.

In view of the fact that Ms C's headache was not reasonably investigated, we upheld Mr C's complaint that the board failed to provide Ms C with appropriate clinical treatment on 7 January 2016.  Whilst we cannot say that Ms C's life would definitely have been saved if these tests had been carried out, the adviser has stated that it was probable that Ms C's condition was treatable.

Mr C also complained that the board had failed to address his complaint in a timely and professional manner.  We found that the board's response had not addressed all of the points Mr C had raised and that they should have provided a more detailed response to him in relation to his questions about the failure to take action in line with the relevant medical guidance.  The board also delayed in issuing the minutes to Mr C after meeting him to discuss the matter.  In view of these failings, we also upheld this aspect of Mr C's complaint.

Redress and Recommendations
The Ombudsman recommends that the Board:

• issue a written apology to Mr C for the failure to provide reasonable treatment to Ms C when she attended the Hospital on 7 January 2016;
• provide evidence that steps have been taken in the Hospital to ensure that adult patients presenting with headache are investigated in line with SIGN 107 (the Scottish Intercollegiate Guidelines Network guidance on the Diagnosis and Management of Headache in Adults);
• provide evidence that steps have been taken in the Hospital to ensure that patients are monitored appropriately;
• provide evidence that steps have been taken in the Hospital to ensure that, in appropriate cases, patients are issued with a discharge note in line with SIGN 128 (the SIGN discharge document);
• confirm that this report will be discussed at the Consultant's next appraisal; and
• issue a written apology to Mr C for the failure to provide a satisfactory response to his complaints.

Summary
Mr C, an advocacy worker, complained about the care and treatment Mr A received during and following an admission to Dr Gray's Hospital, Elgin.  Mr A was admitted in a critically ill state, suffering from sepsis due to a chest infection; alcohol withdrawal; and possible effects of malnutrition.  The sodium levels in his blood were noted to have been dangerously low and he was prescribed intravenous (IV) fluids to try to raise them.  However, as a result of the sodium levels rising too quickly, Mr A developed a neurological condition known as osmotic demyelination syndrome and was left profoundly incapacitated.  Mr C complained that Mr A's incapacity, which includes profound speech problems and walking difficulties, was as a result of inappropriate administration of IV fluids.

We took independent medical advice from a consultant physician, who did not consider that Mr A's sodium levels were adequately monitored.  They noted that there were long periods between reviews of blood tests and no evidence that Mr A's fluid prescription was ever adjusted according to his sodium levels.  They said that the rapid rise in sodium levels did not appear to have been considered at all until neurological deterioration was apparent.  We accepted this advice and upheld the complaint.  We were critical of the board for not having proactively arranged to formally review Mr A's care given the unfortunate outcome, and for not having identified learning points following their investigation of Mr C's complaint.

Mr C also complained that, when Mr A was formally certified as not having had capacity to make decisions about his medical treatment, the board did not appoint an advocate.  We noted that subsequent discussions about Mr A's care and treatment were documented with his daughter (Miss A) and other relatives.  We were advised that, as Mr A had living relatives and was not without representation, there was no requirement to appoint an advocate.  We did not uphold this complaint.  In addition, Mr C complained that a decision not to resuscitate Mr A in the event of heart or lung failure was not discussed with Miss A.  Although the extent to which this was discussed with Miss A was not clear, it appeared that she was made aware of the decision retrospectively.  We were advised that it would be reasonable for medical staff to take such a decision, and discuss it with family afterwards, if there is sudden deterioration at a time when family could not be reached.  However, this was not the case with Mr A and his poor health was chronic in nature, with no signs of recovery over time.  We, therefore, concluded that there was an opportunity for the decision to have been discussed and agreed with Miss A prior to it being taken.  Given this, and the fact that there was no clear evidence of an explicit discussion afterwards, we upheld this complaint.

Finally, Mr C also complained about a lack of medical review following Mr A's discharge, noting that he had not had any further contact from the hospital.  We were advised that hospital follow-up would only be arranged if there was any potential benefit from review in a specialist led clinic.  In Mr A's case, we were informed that there was no routine requirement for further medical input and that any necessary medical interventions for complications could reasonably be handled by his GP.  We, therefore, did not uphold this complaint.  However, we noted that the discharge arrangements did not appear to have been made clear to Mr A.  While these were set out in the discharge letter that was sent to his GP, we identified that this was not sent until almost four months after discharge.  We considered this unacceptable and made some further recommendations.

Redress and recommendations
The Ombudsman recommends that the Board:

• carry out an adverse event review of this care episode, taking account of the failings this investigation has identified, and inform us of the steps they have taken to avoid a similar future occurrence;
• apologise to Mr A for their failure to appropriately manage his fluid intake and for the serious impact this failing has had on his health and quality of life;
• carry out a review of the DNACPR process and take steps to ensure that these decisions are appropriately discussed with patients' representatives, where possible;
• apologise to Mr A and Miss A for failing to appropriately discuss the DNACPR decision with Miss A;
• provide us with an assurance that processes are in place to avoid similar future delays in discharge summaries being sent to GPs; and
• apologise to Mr A for the delay in sending the discharge summary to his GP.