Health

Summary

C complained on behalf of their adult child (A), who underwent septorhinoplasty surgery (to improve the function and appearance of the nose) after a rugby accident. C complained about the care and treatment provided to A following the procedure. C had all skin sutures and brace, seven days after surgery, as per the clinic letters. A developed a post-operative infection and was reviewed again 12 days after surgery, when a further suture was removed. More than a year later, A noted black suture material extruding from the scar line on their nose. They were commenced on antibiotics and further review arranged. C complained that the medical records did not support the board’s position that a suture was intentionally left in place and that the board had failed in their duty of candour.

We took independent advice from a consultant otorhinolaryngologist (specialist in ear, nose, and throat medicine). We found the standard of care and treatment when A attended 12 days after surgery unreasonable. We also found that A was wrongly told that all remaining suture material had been removed at that time.

With regard to the suture material which extruded from the scar line more than a year later, we found that the board’s explanation that this suture was intended to remain in place permanently was not supported by the records. Had it been intended to remain in place permanently, it should have been clearly recorded. We found the board had failed in their duty of candour and that it was unreasonable for the board not to have offered A a second opinion, even if that required referral outwith the board area. We therefore upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

What we said should change to put things right in future:

• Practitioners document the number and type of skin sutures placed in a wound.
• Where a second opinion is requested this should be appropriately considered in line with relevant guidance.

In relation to complaints handling, we recommended:

• Complaint decisions should be evidence-based. Complaint responses should be quality assured to ensure decision-making is based on the available evidence. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at HYPERLINK "https://www.spso.org.uk/training-courses" https://www.spso.org.uk/training-courses .

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment given to their late spouse (A) by the practice before A died from metastatic renal cancer. C raised concerns that A was misdiagnosed by the practice and that they did not make appropriate referral for further investigation when they should have done.

In response, the medical practice provided a detailed timeline of appointments, symptoms, treatments, and actions taken. They concluded that A had a complicated medical history and that the fact that A found it difficult to attend face-to-face appointments, made it difficult for doctors to gauge how much pain they were in. The medical practice acknowledged that there was some miscommunication between the practice and secondary care colleagues in physiotherapy.

We took independent clinical advice from a GP adviser. We found that much of the care and treatment provided to A had been reasonable. However, we also found that some consultations were unreasonable, and that red-flags were not always appropriately identified and/or recorded and were not followed up. We also found that the SAER was not completed in line with the guidelines. As such, we upheld both complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

What we said should change to put things right in future:

• Instigated a monthly meeting with professionals to discuss patients with complex medical presentations. Hold gold standard meetings monthly including the clinical team, district nurses, and MacMillan nurses. Identified a number of learning points from the SAER that was carried out.
• Documentation of consultations, examinations carried out, and the points raised and discussed should be accurate and complete. Treatment should be in line with the relevant NICE guidelines specifically in reference to red-flag symptoms and signs. Clinicians should take action to identify if any red-flag symptoms are present and take appropriate action when they are.
• Patients should be escalated/ referred to hospital pathways when their presentation indicates it is appropriate. Communication and interactions with other health care teams should be carried out reasonably and effectively.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the board did not take reasonable action regarding their referrals. C was privately assessed by specialists in England, who recommended hospital admission for tests. C informed Highland NHS Board and it took over 18 months to approve and arrange referrals.

We found that there was an unreasonable delay in progressing C’s respiratory referral and that the board’s communication was inadequate. The board failed to provide reasonable updates, which might have revealed sooner that the hospital C had been referred to had not received their original submission of the referral. Given this, we upheld the complaint.

We found that the board unreasonably delayed C’s neurology referral. The board’s said that the delay was due to uncertainty over a consultant’s approval for MRI imaging and whether C wished to remain a private patient. We found that C had advised that they would request private care be paused pending the board’s multi-disciplinary team discussions. While the decision to refer C to another NHS Board was reasonable, taking six months to action this was not. We upheld the complaint.

Finally, we found that communication with C was inadequate. Given this, we upheld this complaint and note the steps that the board have taken to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that their communications were inaccurate. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
• Apologise to C that they did not take reasonable action regarding the neurology referral. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
• Apologise to C that they did not take reasonable action regarding the respiratory referral and that they did not keep C reasonably updated regarding the progress of the referral. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

What we said should change to put things right in future:

• Communication with patients whilst referrals are being discussed, or pending a response, is proactive, open, honest, and regular.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided by the board during a planned caesarean section. C said that complications occurred during the procedure which could have been avoided based on information available from antenatal scans. C also complained about the timing of the procedure, record keeping, delays in arranging a debrief meeting, postnatal care for high blood pressure and infection, and the board’s handling of the complaint.

We took independent advice from a midwifery adviser. We found that the care C received during the caesarean section was of a reasonable standard. It was reasonable to schedule C last on the theatre list due to an active COVID-19 infection, and there were no clinical indicators requiring enhanced planning. While complications occurred, we found that these were reasonably managed. We found that offering C the option of vaginal birth reflected good practice. We did not uphold this complaint.

In relation to C’s post-natal care, we found that the monitoring and management of blood pressure, infection treatment, and follow-up care were appropriate and in line with clinical guidance, and the medical records were accurate. We did not uphold this complaint.

We considered C’s complaint about the board’s handling of their complaint. We found that the board acted unreasonably by refusing to investigate on the grounds of time limits, despite the delay being due to a postponed debrief meeting and reassurances given that a complaint could still be made. The board did not provide a clear explanation for refusing to extend the timescale, contrary to complaint handling guidance. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

In relation to complaints handling, we recommended:

• Complaint investigations should be managed inaccordance with the Model Complaint Handling Procedure. The board should ensure that their complaints handling complies with the SPSO Statement of Complaints Handling Principles| SPSO. We offer SPSO accreditedComplaints Handling training. Details and registration forms for our onlineself-guided Good Complaints Handling course (Stage 1) and our onlinetrainer-led Complaints Investigation Skills course (Stage 2) are available athttps://www.spso.org.uk/training-courses.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment that they received from the board.Towards the end of their pregnancy, C contacted the Maternity Assessment Unit due to reduced fetal movements. After phone advice and subsequent in-person assessment, they were discharged home.

C again reported concerns at 39 weeks and 5 days gestation at a routine community midwife appointment. Fetal movements were discussed and further review was advised the following week. At the next appointment, tests were carried out,which sadly confirmed fetal loss. Labour was induced, and C delivered their baby.

We took independent advice from a senior midwife. We found that the board provided a reasonable standard of maternity care and treatment to C. We found that fetal movements were appropriately discussed, measurements were consistent with earlier assessments,and it was reasonable not to arrange additional investigations. We did not uphold this complaint.

Summary

C complained about the care and treatment that their spouse (A) received from the board during admissions to Dr Gray’s Hospital (Hospital A) and Aberdeen Royal Infirmary (Hospital B).

A was admitted following episodes of vomiting blood and received treatment for gastric varices (enlarged blood vessels in the stomach lining). C complained that the board did not investigate or treat A’s condition timeously, and that treatment was only given when their condition deteriorated. C complained that an oesophageal perforation occurred as a complication of a procedure to stop bleeding. C also complained about aspects of nursing care at Hospital B.

We took independent advice from two advisers, a consultant hepatologist, who provided advice on the medical care and treatment, and a senior nurse, who provided advice on the nursing care and treatment.

In relation to Hospital A, we found that there were aspects of A’s care which had been reasonably managed. Specifically, a recognised tool was used to assess the severity of the upper gastrointestinal bleeding which had occurred. However, there were aspects of A’s care which we considered unreasonably managed. In particular, having identified A as being at high risk of bleeding, there were delays in acting on this result, arranging diagnostic endoscopy, and making a timely referral and transfer to Hospital B for ongoing treatment. On balance, we upheld C’s complaint about Hospital A.

In relation to Hospital B, we found that it was reasonable to seek specialist advice about the treatment of A’s condition from another health board. While a complication had occurred when inserting a tube to control bleeding, we found that the management of this was reasonable. We also found that Hospital B had reasonably acknowledged the nursing care incidents which had occurred and taken appropriate steps to learn and improve from them. However, there were aspects of A’s care and treatment which were unreasonably managed by Hospital B. In particular, having identified A as being at high risk of further bleeding, there was an unreasonable delay in providing definitive endoscopic treatment. On balance, we upheld C’s complaint about Hospital B.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

What we said should change to put things right in future:

• Patients presenting with confirmed variceal bleeds should be offered treatment appropriate to their presentation, assessed risk, and ongoing symptoms. When a complication occurs following placement of a Sengstaken-Blakemore tube, the action taken should be appropriate and without risk of harm to the patient.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided to their late parent (A) by the board.

A, who was diabetic, had been diagnosed with conditions including Myasthenia Gravis (an autoimmune disorder causing muscle weakness). A was admitted to University Hospital Crosshouse (UHC) as an in-patient four times, initially with a diabetic foot ulcer. This deteriorated over the course of time leading to infection, surgery and amputation. A died during their fourth admission.

The board partly upheld C's complaint and identified failures in A’s care, particularly around the administration of medication for the treatment of Myasthenia Gravis and around communication with A’s family. They identified learning and improvements.

C remained unhappy and asked us to investigate. C complained that A had been provided with inadequate care and treatment as a podiatry out-patient and as an in-patient at UHC. C also complained that the board had failed to adequately investigate their complaint.

We took independent advice from a consultant vascular surgeon. We found that the out-patient podiatry care provided to A was reasonable and did not uphold this complaint. However, while we found that, overall, A’s care and treatment was reasonable during their in-patient admissions, there were failings in relation to A’s Myasthenia Gravis medication and in communication with A’s family. We upheld this complaint and recommended that the board provide us with evidence of the implementation of the learning and improvements they had previously identified.

We found that the board’s investigation of C’s complaint was reasonable. However, we were critical of the time taken to respond to the complaint and of the board’s failure to keep C regularly updated on the progress of their investigation. We noted that the board had accepted this and identified learning and improvements. We made no further recommendation for action.

Summary

C complained that the practice failed to act reasonably on the symptoms and information provided by C to the practice. The practice acknowledged difficulties in handling the complaint and failed to manage its interactions with a specialist laboratory. C has since transferred to a different practice, and has a diagnosis of Sjogren’s syndrome (a disorder of the immune system where the glands that produce fluid, such as tears and saliva stop working properly). C stated that they had specifically raised these concerns with the original practice and believed that their symptoms and related concerns were unreasonably dismissed.

We took independent medical advice from a GP adviser. We found that C should have been offered a face-to-face appointment. This would have allowed appropriate assessment of C’s symptoms and the possibility of an earlier diagnosis, although this could not be determined with certainty. Therefore, we found that the actions of the practice were unreasonable. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to offer a face-to-face apology. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

What we said should change to put things right in future:

• Review their process for following up blood tests when a laboratory fails to analyse them.
• Wherever possible and where it is clinically appropriate, patients should receive face-to-face appointments, where a detailed clinical examination can be carried out, a detailed history taken, along with a full assessment of any symptoms.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided to their late spouse (A) during their admission to hospital. A was admitted with symptoms suggestive of a stroke and significantly elevated blood pressure. Initial CT imaging and angiography (a type of x-ray used to check blood vessels) were inconclusive, and possible diagnoses included stroke, hypertensive encephalopathy (brain dysfunction caused by severely elevated blood pressure), or a post-ictal state (following a seizure). An MRI scan was planned but aborted for safety reasons. A’s condition later deteriorated, and a repeat CT scan showed stroke in the back of the brain. A died a day after admission.

We took independent advice from a consultant stroke physician. We found that there were aspects of A’s care which were reasonable, including prompt assessment, appropriate imaging, decisions made regarding treatment of blood clots, and MRI scanning and safety. We found that it was also reasonable to consider and treat hypertensive encephalopathy. However, we found that record-keeping fell below the expected standard. In particular, there was a failure to keep contemporaneous records on the day that A was admitted as there was no repeat National Institutes of Health Stroke Scale score noted after the initial CT scan. There was also inconsistent recording of staff grades, which reduced clarity regarding levels of clinical oversight. This added to uncertainty about the diagnosis, but it did not affect A’s outcome. We upheld this part of C's complaint.

C complained about the board's communication with A and their family during the admission. We found that that the board reasonably explained the working diagnosis, management plan and diagnostic uncertainty. Where miscommunication occurred, the board acknowledged this and apologised. Overall, we found that communication was reasonable and did not uphold this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Medical records should be comprehensive and completed in line with professional standards.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained on behalf of their child (A) who is in their late teens. C complained that Child and Adolescent Mental Health Services (CAMHS) failed to carry out appropriate Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) assessments and failed to provide A with appropriate support for a number of years.

The board said that A had undergone a number of assessments and reviews within CAMHS prior to turning 18 and no conclusive diagnosis had been reached. During our investigation they acknowledged that the family may have been unintentionally given the impression that an ASD diagnosis was likely or expected.

We took independent advice from a clinical psychologist with experience in CAMHS. We found that while there were multiple professionals involved, given the complexity of this case there should have been further demonstration of shared, integrated clinical reasoning by the multidisciplinary team (MDT) in formulating a diagnostic conclusion.

We further found that there was a lack of documentation regarding clinical reasoning for the type of psychological therapy offered; and that there was a lack of clarity about the expected/communicated timescales for ASD assessment. Therefore, we upheld C’s complaint.

We noted the board’s explanation that service changes have been implemented and are ongoing since the events considered in this investigation, and that this work is being informed by the Scottish Government and the National Autism Implementation Team. It may be that some of the issues identified in this investigation have been addressed by improvements already made. If that is the case, evidence of those improvements can be provided in support of the recommendations being fulfilled.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A that care and treatment provided to A by CAMHS was unreasonable. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
• Offer A a second opinion, including consideration of whether re-assessment for ASD, and/or an assessment for ADHD, are required.

What we said should change to put things right in future:

• Clear communication with families about expected timeframes should be standard practice and documented in the medical notes.
• Communication around diagnostic uncertainty where neurodevelopmental conditions are being considered should aim to minimise the likelihood of families forming premature expectations about specific diagnoses.
• For complex or borderline cases, the service should ensure that diagnostic conclusions are reached through an integrated multidisciplinary team discussion.
• When psychological therapy options are reviewed, clinical reasoning for the chosen intervention should be explicitly documented.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.