South of Scotland

Summary
Mrs C complained about the care and treatment provided by the board to her late husband (Mr A).  Mr A was diagnosed with pseudomyxoma peritonei (a very rare type of cancer that usually begins in the appendix) and the clinicians involved in his care decided to arrange for scans to be carried out every six months to monitor any development of the cancer.  However, after two scans, further follow-up was not arranged.  Mrs C complained that Mr A did not receive treatment for the pseudomyxoma peritonei until four years after the initial diagnosis, by which point it had progressed considerably.

During the investigation, we took independent medical advice on Mr A's care and treatment from two consultants in colorectal surgery, one of whom has extensive experience in the treatment of pseudomyxoma peritonei.  We found that the delay in Mr A receiving treatment was largely due to a failure to review a scan that was carried out and make further appointments to monitor Mr A's condition.  However, we also found that there was a failure of board staff to discuss Mr A's case at a multi-disciplinary meeting when he was first diagnosed, and to discuss Mr A's case with a specialist pseudomyxoma peritonei unit.  We further found that there was a failure of the responsible consultant to communicate with Mr A and his GP regarding the diagnosis.

Mrs C also complained about the handling of her and Mr A's complaints.  Mr A's first complaint to the board did not receive a response.  When Mrs C later made a complaint, it did not receive a response for over a year, and Mrs C had to regularly contact the board for updates as they were not keeping her informed of progress.  The final response that Mrs C received was a copy of an investigation that had been carried out into Mr A's care, and did not address all of the issues raised in the complaint, apologise to Mrs C and Mr A for failings identified, or give information as to remedial action taken or proposed.  Additionally, details of how to contact the SPSO were not given to Mrs C.  I considered the large number of failings in basic and fundamental complaints handling principles to be unreasonable.

Redress and recommendations
The Ombudsman recommends that the Board:

• apologise to Mrs C for the failings identified in complaint (a) in relation to the delay in treatment for Mr A's pseudomyxoma peritonei;
• provide evidence that MDT meetings are being held to discuss this type of cancer in line with their standards;
• review their processes for ensuring that scan results are reviewed and followed up, and ensure that current processes are sufficient to avoid a repeat of the failings identified by this investigation;
• consider implementing a policy to discuss the treatment options for all cases of proven or suspected pseudomyxoma peritonei with a specialist unit;
• draw the comments of Adviser 1 regarding communication of diagnoses to patients and GPs to the attention of the relevant consultant;
• apologise to Mrs C for the failings in complaints handling identified by this investigation;
• remind the relevant staff that formal complaints should be passed on to the complaints department; and
• review their handling of this complaint and identify areas for improvement.

Summary
Mrs C complained about the care and treatment her late husband (Mr C) received at Raigmore Hospital after he attended the Emergency Department (ED) by ambulance.  Despite Mr C being initially diagnosed with a chest infection, his condition deteriorated suddenly and he died the following day.  Mrs C questioned whether her husband was given appropriate treatment and complained that staff did not properly communicate with her.

When the board investigated Mrs C's complaint, they did not identify any failings in relation to the treatment provided to Mr C, although they acknowledged that staff could have communicated better with Mrs C.

We took independent advice from a consultant in emergency medicine and a consultant cardiothoracic anaesthetist.  We were concerned about significant failings the emergency medicine consultant adviser identified in relation to the treatment Mr C received whilst in the ED, including the fact that the board's local investigation of the complaint did not pick these up.  We accept that the treatment in the ED led to Mr C's abrupt and unexpected deterioration.

Whilst we found that the care provided in the Intensive Treatment Unit (ITU) was of a reasonable standard, we were critical of the communication with Mrs C about her husband's continuing deterioration.  We found that Mrs C had been waiting for a significant period of time in a side room in the ED when ITU staff were trying to contact her and that this was likely the result of poor documentation and communication by ED staff.

Redress and Recommendations
The Ombudsman recommends that the Board:

• conduct a Significant Event Analysis (SEA) into the care Mr C received in the ED in order to identify appropriate improvements in clinical practice and share these findings with the family and my office;
• ensure that the findings of this investigation and the outcome of the SEA are shared with the doctors involved in Mr C's care in the ED and discussed at their next appraisal for shared learning and improvement in clinical practice;
• conduct a review of the complaint in order to explore how the complaints handling failed to identify these issues;
• provide documentary evidence showing the steps that have been taken to improve triage record-keeping;
• apologise to Mrs C and the family for the failings this investigation has identified; and
• share these findings with relevant staff who had been involved in Mr C's care to highlight the importance of documenting conversations with relatives to ensure effective communication between hospital wards.

Summary
Ms A, who suffered from a number of physical disabilities and other conditions, began to complain of headaches in December 2013.  She had surgery to remove a nasal ulcer, and a CT scan revealed no abnormality of her sinuses.

Subsequently, Ms A attended the practice on a number of occasions complaining of vomiting and headaches.  At the same time, Ms A’s mother contacted NHS 24 with concerns about Ms A and she was seen by the board’s out-of-hours service. Ms A’s medical practice prepared a referral letter to neurology.  In the meantime, Ms A was admitted to the surgical service at Raigmore Hospital with abdominal pain.  Ms A was seen by a neurologist on the ward and diagnosed with occipital nerve compression.  Following her discharge, Ms A was seen by GPs from the practice, again with headaches and other symptoms.  Ms A was given an appointment for an MRI scan.  Ms A died at home before this could be carried out.  A post-mortem found that the cause of death was a haemangioblastoma (a tumour of the central nervous system within the brain).

During the investigation, my complaints reviewer sought advice from a GP, a nurse, a neurologist, a neuroradiologist, and a neurosurgeon.

I found the practice did not provide a reasonable standard of care in relation to the examination and referral of Ms A’s headache symptoms.  I also found the board’s out-of-hours service failed to provide Ms A with appropriate care and treatment.  Regarding Ms A’s admission to hospital, I found failings in relation to the neurological examination recorded and a failure to review a CT scan of Ms A’s sinuses.

I am also particularly critical of the way the board handled this complaint and their lack of focus on their failings and ways to improve their services.

Redress and recommendations
The Ombudsman recommends that the practice:

• apologise to the family for the failings this investigation has identified;
• conduct a significant event analysis for review by this office; and
• confirm that the staff involved will discuss this issue as part of their annual appraisal, including identifying the relevant Scottish Intercollegiate Guidelines Network (SIGN) and Scottish Cancer referral guidance as a learning.

The Ombudsman recommends that the board:

• apologise to the family for the failings this investigation has identified;
• confirm the out-of-hours staff identified will discuss this case as part of their annual appraisal, including identifying the relevant SIGN and Scottish Cancer referral guidance as a learning point;
• assess the performance of the out-of-hours staff involved, and identify any training needs;
• confirm the neurologist will discuss this case as part of their annual appraisal;
• should review arrangements for ward consultations (including considering the availability of previous scans for review and encouraging consultants to dictate letters as if it were an out-patient consultation);
• conduct a significant event analysis for review by this office, given the seriousness of this case, and my findings;
• provide my office with an explanation of why a serious incident review was not undertaken in this case; and
• review complaints handling in this case to establish why the failings in care were not identified.

Summary
Miss C complained about how the board had treated her finger injury, and how they dealt with her complaint.  Miss C was employed on a dairy farm, where she suffered a crush injury to her left ring finger.  Miss C was taken to the Dumfries and Galloway Royal Infirmary where she underwent surgery.  Miss C said she had been told that her finger would undergo a partial amputation, which she had consented to.  This procedure would have allowed her to return to work in the shortest possible time period.

Miss C said that she had asked to speak to the board's complaints team to make a formal complaint whilst still on the ward, but that no action had been taken by the board.  She had subsequently submitted a formal complaint, but the board had maintained the surgery she underwent was the surgery she had consented to.

We took medical advice on Miss C's treatment and the consent process undertaken by the board.  The advice said that Miss C had not had her consent properly recorded.  The procedure that was undertaken was not that listed on the form.  Additionally no record had been made of any discussions with her, despite the form containing clearly marked sections for this.  The advice said no treatment plan was recorded, nor was the rationale for performing surgery other than a partial amputation recorded.  The advice stated the failure to perform a partial amputation on Miss C's finger had significantly prolonged the healing process and it was clear from her submissions that her primary motivation was to return to work as soon as possible.

We found the board's records of the consent process were inadequate and that the operation performed on Miss C was not the procedure she had consented to.  The board were unable to explain this, instead maintaining that Miss C had undergone the appropriate surgery.  We also found the board's investigation into Miss C's complaint had been inadequate.  It had failed to identify the lack of records supporting her consent as a concern and had failed to obtain a statement from the doctor responsible for documenting this and performing the surgery for his actions.  Additionally the board's complaint response misrepresented the records of Miss C's interactions with medical staff and failed to address Miss C's concerns about the financial impact of the surgery on her.

Redress and recommendations
The Ombudsman recommends that the board:

• review their process for obtaining informed consent, taking account of the failings this investigation has identified and relevant guidance in this area;
• provide evidence Doctor 1 has undergone training and suitable continuing professional development courses to improve their communication skills and understanding of the consent process;
• carry out a significant event analysis ensuring that Doctor 2 reviews his understanding of the consent process and the definition of a finger terminalisation procedure;
• provide evidence that both Doctor 1 and Doctor 2 have reflected on the failings identified in this report as part of their appraisal process;
• review their complaints investigation in light of the comments from the adviser;
• review their handling of Miss C's complaint in order to identify areas for improvement and ensure compliance with their statutory responsibilities as set out in the 'Can I Help You' guidance; and
• apologise for the failings identified in the report, acknowledging that the procedure performed on Miss C was not the one that she wished to have carried out.

Summary
Mrs A complained about the care and treatment she received from the board. Mrs A died before I completed my investigations and so her complaint was taken on by her daughter (Mrs C).

Mrs A attended University Hospital Crosshouse. She was told that she may need a heart valve replacement but that before this could go ahead, she would need to undergo a cardiac angiogram (a type of x-ray used to examine blood vessels), which is an invasive procedure.  Mrs A gave consent and underwent an angiogram in a second hospital run by the board.  Mrs A said that she experienced pain during the procedure and asked for it to be stopped.  The procedure continued but Mrs A did not recover well and while no abnormality was obvious, her condition did not improve.  Mrs A's level of consciousness declined and a few days later she was noted to have lost power in her lower limbs.  A scan of her spine showed evidence of an ischaemic event (like a stroke) within her spinal cord.

Mrs A was transferred to a third hospital (in a different NHS board), where her scan was reviewed.  This showed the appearance of a stroke on the surface of the brain. Mrs A did not recover the use of her lower limbs.

Mrs A complained that she had not been warned of the possible risks associated with an angiogram.  She also complained of an unreasonable delay in confirming a stroke and that as a result her treatment was delayed.

The board said that Mrs A had made informed consent for the procedure and  recognised that there had been a delay in diagnosis.  They added that even if a stroke had been confirmed sooner, it was unlikely there would have been a different outcome regarding surgery or spinal cord recovery.

I took independent advice from a consultant cardiologist and from a consultant neuroradiologist (a specialist in the analysis of injuries of the brain). The advisers found no evidence that all the risks and benefits of an angiogram had been discussed with Mrs A, including that bleeding and vascular damage that could cause a possible stroke or heart attack are a recognised complication.  I also found the board's consent forms and printed information to have been inadequate.  I established that there was an error in interpreting Mrs A's scan and that her diagnosis had been delayed, although Mrs A's treatment and outcome were likely to have been the same had an earlier diagnosis been made. I therefore upheld the complaint.

Redress and recommendations
The Ombudsman recommends that the Board:

• make a formal apology to Mrs C for their failure to consent Mrs A properly;
• review their consenting procedure and update it in accordance with General Medical Council guidelines.  They should demonstrate to me that they have done so;
• review their relevant information booklet/sheet to ensure that they reflect the appropriate guidelines; and
• apologise to Mrs C for the delay in Mrs A's diagnosis.

Summary
Mr C had a hip replacement operation at Raigmore Hospital.  During the operation, he was aware that the first attempt to insert the implant into his hip had not been successful, and the surgeon had tried again.  This had prolonged the time he was in theatre, and, given the length of time the operation was taking, Mr C had asked for further anaesthesia for the pain.  He found the experience to be very distressing and complained that the board had not provided him with a reasonable standard of care.

I took independent advice from two advisers; one a consultant in orthopaedic surgery (adviser 1) and the other a consultant anaesthetist (adviser 2).  Whilst there were some difficulties during the procedure, of which there is more detail in my full report below, adviser 1 considered that the standard of surgery was reasonable.  However, adviser 2 reported that Mr C was uncomfortable for over an hour until the anaesthetist administered a general anaesthetic, and it would have been reasonable for this to have been undertaken earlier.  Based on this, I upheld Mr C’s complaint about the care he received in his operation.

Mr C was discharged from hospital, and he was given aspirin to take.  However, around two weeks later he was readmitted to hospital with a pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs).

There are national guidelines, issued by the Scottish Intercollegiate Guidelines Network (SIGN) and the National Institute for Health and Care Excellence (NICE), which relate to the use of treatments to prevent VTE (the formation of blood clots in the vein).  These guidelines state that aspirin is not considered an adequate treatment for reducing the risk of VTE for patients in hospitals.

The advice I received from adviser 1 is that the failure to follow the guidelines on treatment following his surgery led to a significant injustice to Mr C in that he suffered a life-threatening condition which required another admission to hospital for treatment.  The surgeon who carried out the surgery had noted in Mr C’s operation note that he should receive anticoagulant therapy but another member of staff had discharged Mr C with aspirin.  However, the surgeon had gone on to tell my complaints reviewer that it was common throughout Scotland for aspirin to be provided for patients who had undergone joint surgery, even though this is against recognised SIGN guidelines.  The board confirmed to my complaints reviewer that there was no specific board policy on this, but that if anticoagulant therapy wasn’t provided to a patient, this should be documented and explained by the clinician taking that decision.

I am very concerned not only that the relevant guidelines were not followed in Mr C’s case, but also about the board’s practice in general.  It remains unclear to me if the board have a coherent policy that is being followed within Raigmore Hospital and beyond.  As a result, an urgent review is required. I also intend to write to the Chief Medical Officer to draw their attention to my concerns about the use of aspirin and its potential implications for patient safety which have come to light in the course of my investigation.

Redress and recommendations
The Ombudsman recommends that Highland NHS Board:

• bring adviser 2’s comments in relation to anaesthesia to the attention of relevant staff;
• review as a matter of urgency the practice to ensure that its surgeons take into account the relevant guidelines on VTE prophylaxis;
• review its standard operating procedures concerning VTE prophylaxis for patients on discharge taking into account the relevant guidelines; and
• apologise to Mr C for the failures this investigation identified.

Summary
Mrs A, who had dementia, was admitted to Borders General Hospital with sepsis (blood infection).  She was discharged to her care home after a few weeks but was re-admitted two months later for end of life care.  She died in hospital two days later.  Her daughter (Mrs C) complained about several aspects of the care and treatment received by Mrs A during her admissions to the hospital.  She said that, before her first admission to the hospital, Mrs A had been able to walk with the help of a walking stick and could feed herself.  However, by the time of her discharge, she could neither stand nor eat without assistance.  Mrs C said that Mrs A was not helped with personal care, her skin care was not attended to, and she was not helped with eating or drinking.  She said that staff did not consider the needs of Mrs A as a person, despite the care home providing 'Getting to Know Me' documentation when she was admitted.

As part of my investigation I obtained independent advice from a nursing adviser.  The adviser noted that the record-keeping, and particularly the nursing notes, about Mrs A's care was poor.  Documents such as her care plan were not completed properly and other documents that my adviser expected to see (such as a wound chart, and food and fluid charts) were missing entirely.  This meant that there was no evidence to show that reasonable nursing care was provided to Mrs A. The adviser said it was very poor that relevant personal information about Mrs A was lacking from her notes as this information was vital to ensure her care plan was person-centred.  I was advised that Mrs A's care lacked any knowledge of dementia, and I am concerned that her needs and preferences were not taken into account.  I concluded that Mrs A did not receive adequate care during this admission.

Mrs C also complained about communication from staff during Mrs A's first hospital admission.  Despite the family holding welfare power of attorney for Mrs A, she said staff never approached them to discuss treatment or the care plan.  She said the family, who made daily enquiries, were often given misleading information, and she complained that the staff discussed Mrs A with them in the corridor.  The adviser said that they would have expected more information in Mrs A's notes about communication with her family, and that the standard of communication was generally poor.  They considered confidential discussions taking place in hospital corridors to be totally unacceptable practice.  I found that the welfare power of attorney should have been identified and reflected in Mrs A's care plan, and the family should have been updated regularly.  An inspection in 2012 by Healthcare Improvement Scotland (HIS) alerted the board to instances where staff failed to satisfy themselves that a welfare power of attorney was in place, and also instances where staff discussed confidential patient information in corridors.  I was concerned that this was still occurring.

Mrs C was also unhappy about the care Mrs A received when she was re-admitted to Borders General Hospital for end of life care, and about the attitude and communication of nursing staff at that time.  She said that Mrs A, who was close to death, and her grieving family were left alone for two and a half hours.  She said the staff showed no care or compassion and seemed uninterested.  The adviser said the nursing role is to care and support both the patient and their relatives, and that they would have expected staff to assess and provide care to a dying patient at least every two hours.  However, there were long gaps between entries in the nursing records, which I found concerning.  The family's needs were clearly not met and I conclude that the level of support provided was unreasonable.

Mrs C complained about the board's handling of her complaints, one of which did not acknowledge within the correct timescale or automatically treat as an official complaint.  The board also failed to send Mrs C a written follow-up or apology after their meeting with members of the family.  Mrs C considered that the board's investigation missed serious failings and, in particular, a breach in procedures that were put in place after the HIS inspection.  I found that Mrs C's letter was clearly a complaint and should automatically have been dealt with as such, and that it would have been good practice to summarise the key points of the meeting for Mrs C.  I considered that the board's learning from the complaints was vague, and I agreed with Mrs C that the board's action plan was insufficient.  I upheld all of the complaints and made several recommendations.

Redress and recommendations
The Ombudsman recommends that the board:

• carry out a review of nursing care and leadership on the relevant wards, taking account of the failings highlighted in this report;
• further develop their action plan to take account of the criticisms in this report and, in particular, ensure that specific and robust action is taken to address the identified record-keeping failings and the failure to provide appropriate, person-centred dementia care to Mrs A;
• carry out a review of their consent to treatment policy and patient documentation to ensure that the existence of any formal adults with incapacity arrangement is promptly identified, reflected in the care plan, and that appropriate communication with the relevant appointed person(s) takes place;
• take urgent action to address the issue of confidential patient information being discussed by staff in hospital corridors and inform the Ombudsman of the steps taken;
• provide us with a copy of their action plan / strategy for end of life care;
• ensure they have a policy in place to guide staff in what they should do when a patient dies;
• review their handling of this complaint and identify areas for improvement, taking account of their statutory responsibilities as set out in the CIHY guidance; and
• apologise to Mrs C and her family for the failings this investigation has identified.

Summary
Mrs A had a form of dementia and was being looked after at home by her family.  When the family became unable to care for her at home, she was admitted to New Craigs Hospital, with the aim of assessing her mental health and finding appropriate medication to enable her to return home.  Following falls in hospital, however, Mrs A's physical health deteriorated.  She was transferred to Raigmore Hospital, where she was found to have a fractured pelvis and urine retention.  Her daughter (Mrs C) made complaints about the admission process and the care and treatment Mrs A received at New Craigs Hospital.

As part of my investigation, I obtained independent advice from a psychiatric nurse, a psychiatrist and an elderly medicine specialist.  Mrs C complained that the board should have admitted Mrs A to hospital for mental health assessment earlier.  I was critical that, from the evidence available, the community mental health team did not provide enough information and advice about the waiting list and what to do if the situation deteriorated.  However, the advice I received was that keeping Mrs A at home whilst waiting for a hospital bed was reasonable in the circumstances.  I did not uphold this complaint.

Mrs C complained about various aspects of the nursing care provided to Mrs A in New Craigs Hospital.  She was particularly concerned about the assessments of falls risk and of Mrs A's pain, the lack of referrals to doctors, the poor monitoring of Mrs A on the ward, and the use of a wheelchair to transfer Mrs A for an x-ray.  The psychiatric nurse adviser was very critical of the nursing care Mrs A received, and concluded that it was disorganised, unsystematic and unreasonable.  They noted the lack of a nursing care plan, poor evidence of falls assessments, and no evidence of proper monitoring of Mrs A's pain.  The psychiatric nurse adviser found that nursing staff failed to bring Mrs A's first fall to the attention of medical staff until a day and a half later, despite clear evidence of bruising and changes in Mrs A's behaviour.  They also commented that it was inappropriate to transport Mrs A in a wheelchair when it was suspected that she had a pelvic fracture.  The advice I received clearly shows that Mrs A did not receive reasonable nursing care.  In particular, I was concerned that nursing staff did not identify changes in Mrs A's behaviour, assess her falls risk, monitor her pain, or ensure that doctors were aware of the situation, even though Mrs C was raising concerns.  I upheld this complaint and recommended an internal review to identify changes.

Mrs C complained about several aspects of Mrs A's clinical treatment, including the way medical staff considered the evidence of her deterioration, and that not enough account was taken of her changing behaviour.  She asked whether more scans should have been taken to investigate Mrs A's pain.  Overall, Mrs C felt that Mrs A should have been transferred to a medical ward much sooner.  The advisers noted that, on admission, Mrs A was mobile and active but, within 48 hours, she was in obvious pain and unable to bear weight.  It is clear to me that when x-rays did not identify a fracture, doctors did not do enough to consider what was causing the pain, or causing changes in Mrs A's behaviour and continence.  Additionally, I was concerned that doctors did not do enough to relieve her pain.  I upheld this complaint.

Mrs C also raised concerns about the record-keeping of the board, particularly with regards to Mrs A's food and fluid intake, falls assessments, the use of hip protectors, and Mrs A's level of consciousness.  My psychiatric nurse adviser found that, for all of these areas, the record-keeping was poor.  Additionally, they were critical that there was no overall care plan so important issues were likely to be neglected, and that record-keeping was mostly retrospective.  It was my opinion that poor record-keeping of Mrs A's care went hand-in-hand with poor care planning and provision, and both were well below reasonable standards.  I upheld this complaint.

I also upheld Mrs C's complaint about the board's response to her complaint about Mrs A's care and treatment.  I found that the response did not fully respond to Mrs C's questions, was overly defensive and lacking in empathy.

Redress and recommendations
The Ombudsman recommends that the board:

• conduct a Significant Event Analysis, aimed at exploring and understanding the causes of the care failures for Mrs A, in order to identify appropriate improvements in clinical practice; and
• apologise to Mrs C for the failings identified in this report, both in relation to Mrs A's care and treatment and in relation to the response Mrs C received to her complaints.

Summary
Mr A was admitted to Borders General Hospital with a heavy nose bleed and in considerable pain.  He had lung cancer and several other medical conditions, and he was terminally ill.  Mr A was initially admitted to the emergency department and then transferred to the medical assessment unit (MAU).  Mr A's partner (Ms C) said that there were a number of failures in the care and treatment Mr A received in hospital.  She complained that the bedside oxygen equipment did not work, that Mr A was not given adequate pain relief or his own medication, and that he was shown a lack of compassion by nursing staff.  She said that Mr A discharged himself from hospital the day after his admission because of the poor care and treatment he had received, and so that he could receive the medication he needed.  He died at home three days later.

I obtained independent advice from a nursing adviser and a medical adviser who is a hospital consultant in acute internal medicine.  Ms C complained that the medical treatment Mr A received in hospital was unreasonable.  My medical adviser noted that the failure of the oxygen equipment in the emergency department would have increased Mr A's feelings of distress.  The board said they had already made changes to ensure that equipment was checked more often, so I asked to see evidence of this.  I also asked to see evidence of the other positive action the board said they had made following Ms C's complaint.  This was to make sure that patients arriving in the MAU were assessed within sixty minutes, whereas Mr A's medical review took place over two hours after arriving on the ward.

My medical adviser said that there was no record of a pain assessment in the emergency department though, on arrival in the MAU, Mr A was assessed as experiencing severe pain.  My adviser considered that pain relief should have been provided earlier in the emergency department.  There was also no record of pain assessment overnight in the MAU.  The advice I have received is that Mr A, who was in acute pain and terminally ill, appears to have received inadequate pain control and was left in pain for considerable periods.  I noted my medical adviser's comment that he could imagine Mr A's frustration at having been left in pain.  In his view, this led Mr A to discharge himself from hospital, leaving his symptoms untreated and with no investigation into the cause of his pain.  Therefore, he was potentially put at significant risk of harm or death.  I upheld the complaint and made several recommendations.

The nursing advice I received identified a number of serious failings in Mr A's nursing care and found that, overall, the nursing care Mr A received in the MAU was unacceptable and poor practice.  My nursing adviser found that nursing staff had failed in their duty to appropriately assess, monitor and alleviate Mr A's pain and did not appear to have followed Nursing and Midwifery Council Standards regarding the prescribing of pain relief medication to Mr A.  My nursing adviser considered that Mr A must have been frustrated not to have had his severe pain relieved despite having his own pain relief medicines with him, which he should have been allowed to self-administer.  My adviser also considered that written statements from the nurses involved in Mr A's care showed a lack of compassion for, or understanding of, his situation and feelings.  I am critical of the board for these failings and the lack of compassion shown to Mr A.  I am concerned that he had such a painful and distressing experience, and I also acknowledge the upset and distress this has caused to Ms C.  I upheld this complaint and made the following recommendations.

Redress and recommendations
The Ombudsman recommends that the Board:

• provide evidence of the action to ensure that oxygen equipment checks are made between patients in addition to standard twice daily checks carried out;
• provide evidence of the action taken to ensure that the assessment of a patient is completed within sixty minutes of the patient arriving in the MAU;
• ensure the comments of the medical adviser in relation to the treatment of Mr A's pain control are brought to the attention of relevant medical staff and they reflect on this;
• apologise to Ms C for the failings identified in Mr A's medical care and treatment;
• reflect again on Ms C's complaint by reviewing what went wrong and what learning has taken place;
• consider implementing learning and development training in early resolution of concerns and complaints for front line nursing staff in the MAU;
• carry out a review of nursing in the MAU to explore the leadership and culture within the ward - to include a review of pain assessment and monitoring of patients in the hospital and, in particular, in the unit; and
• apologise to Ms C for the failings identified in Mr A's nursing care and treatment.

Summary
Mr C complained to the board following treatment he received at Raigmore Hospital.  He was admitted for a haemorrhoidectomy (surgery to remove haemorrhoids) and flexible sigmoidoscopy (a procedure to look inside the back passage and lower part of the large bowel).  Polyps (small growths on the inner lining of the bowel) were found and removed during the sigmoidoscopy.  Mr C was readmitted two days later, after experiencing considerable pain, and it was found that he needed emergency surgery for two holes in his bowel.  Mr C said he was told that, if this second operation was not successful, he would need more surgery and a temporary colostomy bag.  He said that the procedure caused him further pain, stress and anxiety.

Mr C said that he consented to surgery for haemorrhoids and to a flexible sigmoidoscopy on the understanding that the sigmoidoscopy was investigatory, and that he was not told polyps may be removed if identified.  He said that, if he had known of the possibility of damage to his bowel, he may not have had the original procedure done.  He was also concerned that, due to annual leave, the surgeon he had seen before his original day surgery did not perform the operation.

In investigating Mr C's complaints, my complaints reviewer obtained independent medical advice from a consultant colorectal surgeon who is experienced in carrying out the surgery Mr C had done.

My adviser noted that the board’s response to Mr C’s complaint said that the risk of bowel perforation from flexible sigmoidoscopy is low but increased with treatment for polyps.  My adviser referred to General Medical Council guidance on consent which says that doctors must tell patients if an investigation or treatment could result in a serious adverse outcome.  He said that, as the risk of perforation (and, therefore, a hospital admission) is a serious adverse outcome, not having discussed or made a record of such a discussion was unreasonable.  He felt the question of whether polyps should have been removed was irrelevant as the consent process was inadequate.

Regarding Mr C's transfer from the care of the surgeon he had seen before his original day surgery to another surgeon, my adviser explained that it was the responsibility of the surgeon in charge of the case on the day to ensure that a procedure's risks had been explained.  He said that the second surgeon should have ensured that the first surgeon had properly discussed the procedure with Mr C but the evidence did not show that this was done.

In light of the clear medical advice, I uphold the complaints and have made recommendations to the board.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  apologise to Mr C for the failings identified in this report; 28 October 2015
• (ii)  consider introducing pre-printed consent forms for common procedures like this to ensure that such rare (but serious) complications are not missed, and report their findings back to the Ombudsman; and 25 November 2015
• (iii)  consider introducing a review of case notes by the operating surgeon (before the day of surgery) where the patient has been transferred from another surgeon's list, to ensure that the operating surgeon is satisfied the appropriate consent is in place, and report their findings back to the Ombudsman. 25 November 2015