North East Scotland

Summary
Mr A was referred by his GP to the ear, nose and throat (ENT) clinic at his local hospital (in another NHS board area) in January 2014 with a swelling below his left ear.  This was found to be cancerous and Mr A was referred to the board for surgery.  The surgery, which resulted in extensive facial disfigurement, was carried out on 11 March 2014 and Mr A was discharged on 27 March 2014.

Mr A's daughter (Mrs C) complained to the board that they failed to explain the extent of Mr A's surgery and the possible impact on him.  Mrs C also complained about delays following surgery in arranging onward referrals for Mr A to various specialists.

The board noted that the process for obtaining consent for complex procedures such as this takes place over multiple visits, with information being given by different medical professionals.  This is to ensure that patients fully understand the information being given to them.  They said that Mr A appeared to understand the proposed procedure.  They also noted that Mr A was found to be competent and, therefore, able to give consent himself.  They said that staff always try to involve patients' families with this process though there was no formal obligation to do so.  They were sorry that Mr A's family felt they were not adequately involved.

I took independent medical advice from a consultant maxillofacial surgeon (doctor specialising in the treatment of diseases affecting the mouth, jaws, face and neck).  My adviser said that, before such a major procedure, it is important that the patient has all the relevant information, and enough time to discuss it with family and friends, to make an informed decision.  He confirmed that a family presence during discussions is not a legal necessity but said it would be recommended by most doctors.  My adviser also explained that, although Mr A was diagnosed in another NHS board area, it was the board's responsibility to explain the procedure and get consent.  He said that there was a lack of evidence in Mr A's medical notes to show that this was done as it should have been.

In addition, my adviser informed me that most patients who have been diagnosed with head and neck cancer will be seen by a head and neck cancer nurse specialist (CNS), who can help reinforce the issues that have been discussed.

I upheld Mrs C's complaint.  It is crucial that patients are given enough information about planned procedures to allow them to make an informed decision.  They should also be given enough time to make a decision.  The advice I have received, which I fully accept, indicates that Mr A should have been seen earlier by the consultant who performed the surgery, preferably in an out-patient setting with his family and the CNS present.  There is no evidence of any involvement by the CNS, or of relevant patient information literature having been provided.  This may potentially have been provided by the CNS in Mr A's local NHS board area, but I can see no evidence of the board's CNS having taken action to confirm this.  There need to be clearer lines of responsibility when a patient is being referred from one health board to another.

Regarding the complaint about the delays in referrals, my adviser noted that records showed that all the relevant referrals were made within a few weeks of Mr A being discharged from hospital.  However, this was not done by the time of discharge.  This appears to have been as a result of confusion as to which health board was responsible.  I consider that the board ought to have taken steps to clarify this and ensure it was specified in the discharge plan, so I also upheld Mrs C's complaint about the support given to Mr A following his discharge.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  reflect on the failings highlighted in this report with a view to improving the process for obtaining informed consent and report back to me with their findings;
• (ii)  take steps to ensure that there is more involvement of the CNS in similar future cases and that this involvement is clearly documented;
• (iii)  apologise to Mr A and his family for the failings identified in the process for obtaining informed consent;
• (iv)  review their process for treating patients referred by other health boards, and discharging them back into their care, in order to ensure that clear lines of responsibility exist; and 
• (v)  apologise to Mr A and his family for the failings identified in the discharge process.

Summary
Mrs C was admitted to Glasgow Royal Infirmary in January 2013 to get treatment for a skin infection in her left leg.  Mrs C has spina bifida (a condition where the spine does not develop properly, leaving a gap in the spine) and lymphoedema (a build-up of fluid which causes swelling in an area of the body) which means that she has problems moving around.  She developed pressure ulcers on her left heel and calf, which were still there when she was discharged.  When she got home, Mrs C also found that a pressure ulcer had developed on her buttock.  She was readmitted to the hospital in February 2013 as one of the pressure ulcers was infected, and discharged a few weeks later.  She was again admitted in December 2013.

Mrs C felt that, each time she was admitted to the hospital, her risk of pressure ulcers was not properly assessed and that, due to her existing medical conditions, she should have been placed in the 'very high risk' category.  She said that the pressure ulcers developed because of the incorrect assessment and due to a lack of appropriate care.  She said that she had suffered a great deal of pain and discomfort, as well as scarring, which continued to cause her distress.  With the help of an advice worker, Mrs C complained to the board.

The board apologised that Mrs C felt that her pre-existing medical conditions were not taken into account.  They set out the timeline of events across her three admissions to hospital, stating that she had been assessed as requiring a low level of support.  When she had needed a pressure-relieving mattress when she left hospital on the second occasion, they said that this had been provided.

They said that she was assessed by a district nurse at home and continued to receive treatment for a pressure ulcer at the base of her spine until the end of July 2013.  The board said that the readmission notes for Mrs C's third admission to hospital state that her skin was healthy and, although she had previously developed pressure ulcers when she was unwell, she did not require pressure-relieving equipment because she was assessed as being able to adjust her own weight whilst in bed.  The board said it was documented that Mrs C's husband (Mr C) had insisted that a pressure-relieving mattress was ordered for Mrs C, and he had been extremely unhappy that one had not been provided.  Finally, they said that staff had carefully considered Mrs C's condition and treatment, and they were sorry that she had been dissatisfied with her care in the hospital.

Mrs C was dissatisfied with the board's response to her complaint and contacted my office, with the help of an advice worker.  I took independent advice from a nursing adviser who considered that, as Mrs C has spina bifida, she was at very high risk of developing pressure ulcers during her admissions to hospital.  The adviser found no evidence that the nursing staff took Mrs C's pre-existing conditions into account or put steps in place to prevent pressure ulcers occurring.  In particular, the Waterlow risk assessment charts (a pressure ulcer risk assessment tool) completed for each hospital admission were not marked properly.  The adviser said that, as Mrs C has reduced sensation below the waist (because of spina bifida), she should have had five extra points added to her Waterlow score.  This would have put her into the 'high risk' category.  During the second hospital admission, the adviser considered that the delay of several days for a tissue viability nurse to provide advice on Mrs C's care, and for a pressure-relieving mattress to be arranged, was unacceptable.  The adviser also noted that the nursing staff involved in an incident when Mr C was very angry about Mrs C's treatment and the delays experienced may benefit from education and training in front-line resolution.  The adviser also found it 'shocking' that the board had not determined and admitted their failings in Mrs C's care and treatment when they investigated her complaint.

The advice I have received is that nursing staff failed to take into account Mrs C's specific needs due to her spina bifida and, as a result, failed to appropriately assess and manage her pressure areas on each of her admissions to the hospital.  There was also a failure by the board to acknowledge these failings while carrying out their investigation of Mrs C's complaint.  I am critical of these failings and uphold the complaint.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  review the training for nursing staff on the assessment, prevention and care of pressure ulcers, particularly where a  patient has reduced sensation to the limbs;
• (ii)  ensure the tissue viability team review the mechanism for recording patients who are 'special risk', particularly patients with reduced sensation such as spina bifida;
• (iii)  carry out a review of the reasons why there was a delay in the involvement of the tissue viability team in Mrs C's care; and advise this office of the action taken to ensure that lessons are learned from this complaint;
• (iv)  review the education and training in early resolution skills for the nursing staff involved when dealing with patients and their families who have raised concerns about their care and treatment; and
• (v)  apologise to Mrs C for the failings identified in her care and treatment. 

Summary
Mr A had concerns about the care and treatment he received from his medical practice in diagnosing his kidney condition.  An advice worker (Ms C) complained to the practice on his behalf in April 2013.  When she had not received a response to her complaint, despite chasing a response and resubmitting her complaint, she complained to my office.  Ms C noted that the only contact she had with the practice was a reply from them asking her to pay £50 to release Mr A's medical records, which was not what she had asked for.  She was also concerned that the practice was operating outwith the NHS complaints procedure, as her complaint should have been acknowledged within three days and responded to within 20 working days.  My complaint reviewer considered the evidence available, upheld Ms C's complaint and made recommendations to the practice, which were to issue a response to Ms C's original complaint, apologise to Mr A and review their complaints handling procedure.  We published our decision on this case in March 2014.

There then followed several attempts from my office to ensure that the practice had complied with our recommendations.  The correspondence we received from the doctor at the practice noted that the practice had no idea what their mistake was or what they were to apologise for.  Eventually, after making several attempts to correspond with the practice, I wrote to the chief executive of the board to make them aware of the matter.  The chief executive noted that many of the statements made by the practice to my office during our investigation were inaccurate.  In particular, the chief executive confirmed that the mail system within the building in which the practice was located was not dysfunctional (the practice had said that the mail system had led to them not receiving Ms C's initial complaint).

I took independent advice from one of my clinical advisers who is a GP.  He noted that whilst Ms C presented a credible history, the practice appeared to contradict themselves and were less credible with the explanations and information they had provided to us.  My adviser commented that the practice did not appear to have correct and proper systems in place to ensure the safe running of the practice.  In addition, he said the chaotic way in which the practice dealt with Ms C's complaint including treating it as a request for copies of medical records and requesting a payment for £50 was worrying.  My adviser highlighted a number of sections of the General Medical Council (GMC)'s Good Medical Practice guidance, and noted where the practice appear to have failed to demonstrate their compliance with this guidance, including their failure to operate a credible complaints system.

The advice I have received, and accepted, is that the practice had deliberately complicated the issues around Mr A's complaint with the aim of not answering it, which was compounded by the poor systems they had in place for handling complaints.  The practice's failure to engage with the board to allow mediation and assistance to improve their situation led to the injustice of Mr A not having his complaint answered.

Finally, my adviser commented that the actions, and lack of action, taken by the practice were serious enough to threaten the reputation of the medical profession because they had repeatedly failed in the duties expected of them by the GMC.  The evidence available indicates that they failed to handle Ms C's complaint appropriately in line with the NHS 'Can I Help You?' guidance.  In addition, I have extreme concerns about the practice's resistance to accept that they failed to handle the complaint properly.  Their refusal to comply with my recommendations has resulted in my office having to issue this report when the complaint should have been finalised following the decision issued by my complaints reviewer over a year ago.  In light of my serious concerns, I have not only made further recommendations to the practice, but also recommended that the board consider the contract held with the practice, and consider whether to refer the practice to the GMC.

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i)  acknowledge acceptance of Mr A's complaint and answer it appropriately within 20 working days;
• (ii)  apologise to Mr A for failing to deal with his complaint appropriately in line with Can I help you?; and
• (iii)  provide the SPSO with a copy of its complaint handling procedure to demonstrate compliance with Can I help you?.

The Ombudsman recommends that the Board:

• (i)  consider referring the Practice to the GMC; and
• (ii)  consider its position in relation to the contract held with the Practice. 

Overview

Mr C, a prisoner, complained that the prison health centre's handling of his complaint forms was unreasonable.  He also complained that he had problems in accessing the relevant complaint forms.

Specific complaint and conclusion

The complaints which have been investigated are that:

(a) the prison health centre's handling of his complaint forms from 1 to 3 November 2012 was unreasonable (upheld); and,
(b) prisoners' access to Board complaint forms has been unreasonable (upheld).

Redress and recommendation

The Ombudsman recommends that the Board:

(i)  issue a written apology to Mr C for the failure to deal with his complaint in line with their complaints procedure;
(ii)  ensure that the local process in place for the management of prison health care complaints is in line with the good practice outlined in the Scottish Government guidance 'Can I Help You?'; and
(iii)  take steps to confirm that complaint forms are readily available for prisoners to access.

The Board have accepted the recommendations and will act on them accordingly.

Summary
Mr C had an abdominal tumour, and saw a consultant who recommended that the tumour should be surgically removed.  The consultant started Mr C on medication that helps to prevent dangerous rises in blood pressure related to the surgery he was due to undergo.  In January 2013 Mr C completed a consent form agreeing to undergo surgery to remove the tumour.  The form did not specify any potential risks of the operation that the surgeon performing the procedure had discussed with Mr C, or that any discussion had taken place around any extra procedures which may become necessary. Surgery took place the next day.

Mr C was then reviewed the following month by the surgeon who wrote to Mr C’s GP to say that Mr C had reported difficulty with ejaculation but had experienced problems with this in the past.  Mr C was seen by a urology doctor (specialising in problems of the urinary tract and reproductive organs) in November 2013, where Mr C said he was still having problems with ejaculation.  Tests confirmed that Mr C had retrograde ejaculation (where semen enters the bladder rather than coming out of the penis).  Mr C had further follow-up appointments with the consultant who had recommended the surgery, and the surgeon who had carried it out.  Mr C complained to the Board about the lack of information he was given about retrograde ejaculation before the planned surgery, and that the surgeon had told him that he did not foresee any complications arising.

In the Board’s response to Mr C’s complaint, they did not clearly respond to Mr C’s complaint about the information he was provided with during the consent process.  Instead, they focused on the reasons why they felt it was unlikely that Mr C’s operation was the cause of the retrograde ejaculation, and said that this was a problem Mr C suffered from in the past, which Mr C disputed. Mr C then complained to my office.

In considering Mr C’s complaint, I took independent medical advice from a consultant urological surgeon who specialises in sexual dysfunction, who said that whilst the medication Mr C had been prescribed prior to the surgery (to regulate blood pressure) does have a side effect of causing retrograde ejaculation, this would only last for the short time the drug was prescribed and administered.  My Adviser said that the surgical procedure Mr C had was not very common, and, therefore, it is logical to refer to data for similar and more common operations which take place in the same region of the body but for different conditions.  For operations of a similar nature, my Adviser said that retrograde ejaculation is a rare but recognised side effect and this should have been discussed with Mr C when consent was obtained for the procedure.  The Adviser also noted that there are other potentially very serious risks to major arteries and veins when undertaking surgery in this area.

Whether or not Mr C previously reported problems with retrograde ejaculation prior to surgery, I found this was only documented in the post-surgery notes taken a month after the surgery was carried out.  There was nothing in the notes leading up to the surgery about this. In relation to the information Mr C was given, I consider that the surgeon should have warned Mr C about the possible risks or complications.  Whilst the risk of this side effect occurring is very small, General Medical Council guidance says that patients must be told about recognised serious adverse outcomes, even if they are rare.  There is no clear evidence to demonstrate this was done or indeed that discussion took place about other major structures close to the operative area being at risk of injury with possible significant consequences.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  apologise to Mr C for failing to ensure that he was fully informed of the risks associated with his surgery; and
• (ii)  ensure that their consent policy includes guidance on the importance of accurately recording conversations with patients regarding risks and complications as part of the consent process.

Summary
Mrs C was suffering from abdominal pain, and was seen at a gynaecology out-patient clinic following referral by her GP Practice in November 2012.  She was diagnosed with uterine fibroids in January 2013.  Mrs C was admitted to a ward at her local hospital (in another NHS board area) due to the pain.  In February 2013, Mrs C's GP contacted the consultant gynaecologist (Consultant 1) in charge of the out-patient clinic, requesting that she be placed on the list for surgery due to the impact her condition was having on her life.  Consultant 1 replied to say further discussion was required within the multi-disciplinary team; Mrs C was offered another appointment at the clinic on 2 April 2013.  Mrs C decided to seek private treatment, and had successful private surgery on 4 April 2013.

Mrs C made a complaint in June 2013 about the care and treatment she received, as well as communicative difficulties she had had when trying to contact Consultant 1.  She received a reply in August 2013, apologising for the administrative backlog that caused delay with her care and treatment.  The Board also said it was unlikely Mrs C would have been seen earlier than 2 April 2013 due to the gynaecology service's waiting times overall.  Mrs C complained again and the Board issued a final response in February 2014.  At this time, Mrs C was told that, in February 2013, Consultant 1 had made a decision that she should be referred for surgery.  An appointment for 4 April 2013 was to be offered; a telephone call was made by the Board to her GP Practice on 4 March 2013.  Consultant 1 told us that this had been left with the GP to discuss with Mrs C.

My investigation found that more prompt action should have been taken by the Board given Mrs C's worsening condition, and that there was a lack of urgency which meant Mrs C's care plan was not re-assessed.  I concluded that to expect Mrs C to wait for a further clinic appointment in April 2013 was not reasonable.  In addition, it was not reasonable that Consultant 1 had only contacted the GP Practice by telephone to advise of the offer of surgery; contact should have been made in writing to ensure Mrs C was aware of her options.  It was not reasonable to expect the GP Practice to pass on a message about the offer of surgery.  In my view, it was likely Mrs C would not have sought private treatment had she known the same procedure would have been available via the NHS at the same time.  I also found that the Board's responses to Mrs C's complaints were delayed, having been received well outwith the timeframes within the Board's complaints handling procedure.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  reimburse Mrs C for the cost of her private surgery on production of receipts;
• (ii)  apologise to Mrs C for the failures in communication identified in this investigation;
• (iii)  confirm that steps have been taken to address the administrative communication failings identified during their investigation of Mrs C's complaints;
• (iv)  review the gynaecology department's internal and external communication arrangements to determine what improvements can be made;
• (v)  review the management procedure for the care and treatment of patients like Mrs C who live in another NHS board area;
• (vi)  apologise to Mrs C for the delays in responding to her complaints;
• (vii)  confirm that a process has been put in place to ensure that a complainant's further comments are addressed timeously; and
• (viii)  review arrangements with Mrs C's local NHS board for management of similar joint complaints.

Overview
The complainant (Ms C) raised concerns about the Medical Practice (the Practice) on behalf of her client (Mrs A).  Mrs A's complaints relate to her son (Mr B) and attempts to register him at the Practice.  Mr B was in prison but was due for liberation on 18 January 2013.  Whilst Mr B was still a prisoner, Mrs A visited the Practice and completed registration forms for him.  She also made an appointment for the day of his release so that he could obtain antipsychotic medication (medicines used to treat mental health conditions) to alleviate methadone (a drug used medically as a heroin substitute) withdrawal.  Mrs A contacted the Practice on 16 January 2013 and confirmed that Mr B's appointment was booked for 18 January 2013.  Also on 16 January 2013, the Practice Manager received a call from Greater Glasgow and Clyde Patient Registrations advising that Mr B was still registered as 'care of HMP' (care of Her Majesty's Prison) and that he could not be registered elsewhere until he was liberated.  The Practice Manager thereafter cancelled the registration on the system and advised two members of staff to update Mrs A and Mr B.  Neither of the staff members provided the update.  Mr B was released as planned on 18 January 2013.  He attended at the Practice for his appointment and was advised that there was none on the system.  The Practice Manager gave him contact details for the community mental health team, community addictions team and NHS 24.  Mr B left the Practice without seeing a GP.  He died from pneumonia (an infection of the lungs) three days later on 21 January 2013.

Specific complaints and conclusions
The complaints which have been investigated are that:

• Mr B was unreasonably refused access to a GP (upheld); and
• the Practice unreasonably did not respond to further letters related to the complaint (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• apologise to Mrs A and acknowledge that they should have seen and assessed Mr B properly on 18 January 2013;
• provide us with copies of their Significant Event Analysis and Enhanced Significant Event Analysis with their reflections on what happened and why this occurred;
• provide us with their written policies on the registration of new patients and the provision of immediately necessary treatment;
• ensure that all staff within the Practice are fully trained on patient registration and provision of immediately necessary treatment;
• apologise to Ms C and Mrs A for their failure to deal with further complaint correspondence appropriately;
• work with the Board to create a new complaint handling procedure and provide a copy to us for review; and
• ensure that all staff are fully trained on the complaint handling procedure.

The Practice have accepted the recommendations and will act on them accordingly.

Overview
The complainant (Mrs C) raised a number of concerns with Greater Glasgow and Clyde NHS Board (the Board) regarding the care and treatment her father (Mr A) received while a patient in Glasgow Royal Infirmary (the Hospital).  Mr A died in hospital on 26 November 2013.

Specific complaints and conclusions
The complaints which have been investigated are that the Board did not:

• provide reasonable care and treatment to Mr A between 25 October and 26 November 2013 (upheld);
• communicate reasonably with Mr A's family between 25 October and 26 November 2013 (upheld); and
• respond reasonably to Mrs C's complaints about these matters (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• ensure its policies set out clear responsibilities for clinicians to ensure that tests are either reviewed by the requesting doctor, or handed over to colleagues;
• carry out a morbidity and mortality case review  of Mr A's death.  The review should include the actions of the Haematology and Orthopaedic departments and provide evidence that the following points were addressed: the handover procedures followed by medical staff; the care and treatment pathways for the management of patients who fracture their hip whilst on a geriatric ward; the failure to ensure that Do Not Attempt Cardio-Pulmonary Resuscitation was discussed appropriately with the patient or his family; whether the Board's end of life care policies were properly followed; whether Mr A's mental capacity was properly assessed and what procedure should have been followed; review whether there was appropriate and timeous discussion of resuscitation with Mr A's family; review the failure to document in Mr A's records the reason for his ward transfer; review the lack of early Consultant input into case discussions with Mr A or his family;
• include the findings of the morbidity and mortality review in the subsequent appraisal of the consultant responsible for Mr A's care;
• remind all staff of the importance of documenting and signing discussions with patients' families;
• apologise for the failings identified in this report; and
• provide evidence that the actions referred to in the complaint response letter have been implemented.

The Board have accepted the recommendations and will act on them accordingly.

Overview
The complainant (Mrs C) complained about the treatment provided to Mr A, after he was admitted to the Aberdeen Royal Infirmary (the Hospital) with severe chest pain.  Mr A was initially treated as having acute coronary syndrome (a medical term used when doctors believe that the patient has a serious problem with the narrowing of one or more of the coronary arteries) because of an elevated serum troponin (this is present in the bloodstream when there has been damage to the heart).  However, approximately two and a half days after his admission, it was diagnosed that Mr A had a dissection flap (tear) in the ascending aorta (a portion of the large trunk artery that carries blood from the left ventricle of the heart to branch arteries).  Arrangements were made for Mr A to undergo surgery that day, but he died in the anaesthetic room before the operation could begin.

Specific complaint and conclusions
The complaint that has been investigated is that staff at the Hospital failed to provide Mr A with an appropriate level of treatment following his admission in January 2012 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• issue a written apology to Mr A's family for:  the failure to identify that Mr A had aortic dissection when the bedside echocardiogram was carried out on 2 January 2012; and the delay in providing a copy of the bedside echocardiogram to his office; and
• provide evidence that they have taken steps to raise awareness of aortic dissection in their A&E, Emergency Medicine, General Medicine and Cardiology departments.

The Board have accepted the recommendations and will act on them accordingly.

Overview
The complainant (Mr C) raised a number of concerns that his mother in law (Mrs A) had been inappropriately cared for in Perth Royal Infirmary.  Mrs A had been admitted on 15 February 2013, with a sudden loss of mobility.  She was discharged on 13 May 2013, but had not regained the ability to walk.  Mr C said that it was not until later that the family learned Mrs A had suffered a fractured hip.  Mr C said this was not properly diagnosed or treated and that Mrs A was never x-rayed during her stay in hospital.  Mr C was also unhappy with the way his complaints were handled by Tayside NHS Board (the Board), as he felt the internal review process lacked objectivity and dismissed the family's concerns.

Specific complaints and conclusions
The complaints which have been investigated are that:

• the Board provided inadequate care and treatment to Mrs A (upheld);
• the Board's reviews of Mrs A's care and treatment were inadequate (upheld); and
• the Board's handling of and response to Mr C's complaints was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• remind all staff of the importance of discussing completion of the Do Not Attempt Cardio-Pulmonary Resuscitation form with either the patient or appropriate family members;
• review their processes to provide a failsafe to ensure that vulnerable patients are fully assessed to determine their capacity;
• remind all staff involved in geriatric care of the importance of considering hip fracture in elderly patients with loss of mobility;
• review their procedures to ensure that internal case reviews have objective clinical assessment of the available evidence;
• review their procedures to ensure that where additional medical opinion is required, this is obtained in a formal statement from the clinician;
• review its complaints procedure to ensure that all meetings with complainants are formally noted;
• review its complaints procedure to ensure that complainants are provided with notes of all meetings with Board staff conducted under the complaints procedure; and
• apologise in writing to Mr C for the failure to diagnose Mrs A timeously with a hip fracture and for the identified failures in dealing with his complaint.

The Board have accepted the recommendations and will act on them accordingly.