Health

Summary

C complained about the standard of surgery and post-operative care that they received when they had an elective operation for a long standing hernia (when part of an organ protrudes through your muscle wall). During the procedure the bowel was punctured resulting in an injury and transfer to another hospital.

C said that the small hernia was manageable without an operation, and complained that they had not been told about all the risks and about inadequate care post-surgery.

We took independent advice from a consultant general and colorectal surgeon. We found that it was reasonable to offer C an elective repair of the hernia and for this operation be to done by the consultant surgeon. However, more regard should have been given to whether C was at an increased risk due to their BMI. We found that the board failed to provide informed consent at an appropriate time which meant that the risks of surgery were not effectively communicated to C. We also found that the consent process for C did not meet published guidelines. Therefore we upheld this complaint.

We found that post surgery, recognition and escalation to start Patient Controlled Analgesia was appropriate, and that C responded well to this pain relief. The timing of the CT scan was reasonable. Following escalation to clinical care specialists and treatment, C was transferred for further care which was also reasonable. We therefore did not uphold this complaint.

We provided feedback that consideration should be given to the preoperative risk assessment being carried out at consultant level and that referral to specialist weight management is available for patients who require incisional hernia repairs electively.

Recommendations

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

• Relevant staff should be aware of the required consent procedure and to ensure that the consent discussions are appropriately timed in advance of surgery and documented.
• When a relevant adverse event occurs, the board should promptly carry out an SAER to investigate the cause and identify any potential learning.

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 raised concerns about the care and treatment provided to their sibling (A). A underwent a series of hospital admissions, suffering from bleeding from their bladder, following radiotherapy. During these admissions, the majority of communication between the board and the family was with A’s partner (B). A was initially expected to recover from the radiotherapy but was admitted and discharged repeatedly, with some readmissions happening a matter of hours after A was discharged. A continued to deteriorate and died in hospital.

C believed that A was not provided with an adequate standard of urological or nursing care. They felt that A was not provided with appropriate treatment and that they were not reviewed properly by other medical specialties, given the complexity of their case. C was also concerned that A was not provided with adequate nursing care. C believed that the board had not acknowledged systemic failings which impacted on A’s care, wellbeing and adversely affected the outcome of their treatment.

We took independent advice from a consultant urologist and a registered nurse. We found that A’s urology care fell below a reasonable standard, as did their nursing care and we upheld these aspects of the complaint.

We found that A was reviewed appropriately by other medical specialties and this aspect of C’s complaint was not upheld.

Finally, the opportunity to perform surgery on A was missed and this contributed to A’s deterioration. It was not possible, however, to determine whether A would have survived if their care had been different. The board failed to transfer A to a different consultant or offer a second opinion when this was requested and they failed to communicate reasonably with A’s family about their care. We upheld these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should apologise separately to C & B for the failures in A’s care. 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:

• Improved management of long-term or complex patients, with clear communication between different medical specialties. The board should review the management approach to long-term complex patients, focusing on the shared care arrangements between differing specialties.
• Patients admitted to hospital should receive appropriate nursing care including appropriate nutritional and fluid intake monitoring, when requested as part of their care plan.
• A review of whether urology patients can be provided with a dedicated ward, or part of a ward.
• Consultant care transfer and second opinion requests should be managed reasonably and transparently.
• Patients should receive adequate nutritional support to support their treatment and recovery. The board should develop an action plan, reviewing A's case and identifying learning for the staff involved in A's care.
• Patients admitted to hospital should receive reasonable medical care including being offered appropriate treatment options, nutrition, and review after transfer from HDU. Clinical correspondence should be completed to an appropriate standard.
• Patients admitted to hospital should receive appropriate nursing care including appropriate recording of their patient centred care plan.
• Patients admitted to hospital should receive appropriate nursing care including recording and management of wounds or pressure injuries.
• Decisions on surgery should be explained to the patient whenever possible, allowing the patient or their family to make informed decisions about their treatment.

In relation to complaints handling, we recommended:

• Complaint responses should be clear and written in plain English whenever possible. Where clinical terms or technical language is used, this should be clearly explained in the body of the letter.

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 failed to provide their parent (A) with reasonable care and treatment when they attended the A&E with symptoms including a loss of sight in one eye. C raised concerns about the delay in assessing A and failures by staff to reasonably diagnose and treat A. C also said that the board failed to reasonably communicate and provide A and C with sufficient information after A was taken to a cubicle, to provide A with appropriate personal care, to adequately record information about A’s care and treatment and to follow the relevant policies and procedures in providing care and treatment to A.

We took independent advice from a consultant neurologist and a nurse. We found that there was an unreasonable delay in A being assessed by a doctor. We also found that there was poor record keeping in A’s medical and nursing records, which showed the level of care and observation A had received was unreasonable. We found that, had A’s observations been recorded as required, it was possible that a deterioration in A’s condition would have been picked up sooner. Consequently, we found that the care and treatment provided to A in the A&E was unreasonable. We, therefore, upheld this part of C’s complaint.

C also complained that, after A was transferred to the high dependency unit, a consultant neurologist failed to sensitively explain to them about A’s diagnosis and prognosis. We found that adequate and appropriate information was conveyed to C by the consultant neurologist and the communication between them had been clinically appropriate and satisfactory. It was not possible to determine whether or not the consultant neurologist had failed to explain this sensitively. We did not, therefore, uphold this part of C’s complaint.

C further complained that a senior research nurse failed to take reasonable steps to contact them regarding a stroke research study. We found that there was a failure to take reasonable steps to contact C regarding the stroke research study. We, therefore, upheld this part of C’s 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/information-leaflets.

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

• A significant adverse event review should be carried out.
• Basic observations should be carried out to the frequency required for the presenting condition of the patient to allow any deterioration in the patient to be identified timely and acted on as soon as possible. Records should be accurate and reflect the care and interventions carried out to the standard required by the Nursing and Midwifery Council.
• Where a patient safety incident occurs, a datix should be completed. There should also be evidence of reflection and learning for the staff involved in relation to such incidents.

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 adult child (A) by the board. A had received care from mental health services for several years prior to their death by suicide. C complained that the board failed to reasonably share information with A’s family and failed to involve family in A’s care. C also complained about the board’s adverse event review process, and their complaint handling.

We took independent advice from a consultant psychiatrist. We found that the board had failed to evidence that there was any discussion with A about sharing information with their family or involving family in care and treatment, including risk assessment. We considered that not to have had this discussion, or to have had the discussion and failed to document it, was unreasonable.

The board told us that records were kept briefer than they would normally, because A was an employee of the NHS and was concerned about their records being kept confidential. We did not consider this to be a reasonable position to take, as all patients, including those who are NHS staff, should be confident that their records will be kept confidential. We considered it unreasonable that the board had not addressed this concern. We upheld C’s complaint about information sharing and involvement of family.

In relation to the adverse event review process, we found that the board had not appropriately taken account of C’s view on the scope of, and information to be contained within the review, and because it did not identify the failings in care. We upheld this aspect of the complaint.

Finally, we considered the board’s handling of C’s complaint to be unreasonable. This was because answers to multiple questions about care and treatment were responded to using generic and repetitive phrasing, the complaint response contained several inaccuracies and C was not made aware that some aspects of the complaint could only be responded to by another organisation until the final complaint response,. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings with regard to information sharing and involvement of A’s family, the adverse event review process and the complaint handling and response. 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:

• Adverse event review teams should be open to the requests of family when making decisions about scope and information contained in the final report. Adverse Event Reviews should be a reflective and learning process that appropriately consider events in sufficient detail to ensure failings and any appropriate learning and practice improvements are identified.
• Patients who are also employees of the NHS should have confidence that records will be confidential.
• Records should be comprehensive and completed in line with professional standards. In particular, mental health services should seek to discuss involving family in care planning and risk assessment. These discussions and outcomes of such should be documented and revisited regularly.

In relation to complaints handling, we recommended:

• Where some aspects of a complaint cannot be responded to by the board, the board should coordinate responses or make the complainant aware that they need to approach another organisation at the earliest possible point. Complaint responses should attempt to address individual concerns, or explain why that is not possible. Complaint responses should be accurate.

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) who was diagnosed with lung cancer. C considered that there had been missed opportunities to diagnose A earlier, and that as a result A was denied appropriate care which may have affected their outcome. C also complained that the cause of death determined by the board was inconsistent with A’s diagnosis. Additionally, C complained that the cause of death was amended at a later date, which caused them to doubt the accuracy of the board’s conclusions.

In their complaints response, the board stated that X-rays conducted earlier in the year had been reviewed and that radiologists were in agreement that A’s disease could not have been identified earlier. The board had also apologised that the cause of death had initially been determined to be hospital acquired pneumonia, and that this had now been corrected to community acquired pneumonia with lung cancer as the major contributing cause.

We took independent advice from an experienced respiratory consultant. We found that it was not unreasonable that A’s cancer had not been detected on earlier X-rays. However, a decision to downgrade a GP’s referral from ‘urgent suspicion of lung cancer’ to ‘new urgent’ created delays in investigations of approximately four weeks, and likely longer had A not been admitted to hospital unrelated to the referral. Further delays of around three weeks were also apparent between the final investigation and the final multidisciplinary team (MDT) discussion. We also found that it was unlikely that there would have been a different outcome for A due to the nature of A’s illness. As such. we upheld C’s complaint.

Regarding the cause of death, we found that the cause of death had been correctly identified in line with the available information and that whether the pneumonia had been hospital or community acquired was a technicality that was less significant than the overall conclusions. Based on this, on balance, we did not uphold this aspect of the complaint that there had been inaccurate or misleading information provided.

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/information-leaflets.

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

• There should be a robust system in place for triaging respiratory referrals, which should only be downgraded when there is a clear clinical reason to do so. All patients with suspected cancer undergoing investigations should be appropriately tracked to prevent delays.

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 practice’s treatment and diagnosis in respect of issues C had with their leg over a period of 18 months and being diagnosed with deep vein thrombosis (DVT). In C’s view, the practice missed various opportunities to diagnose DVT or refer onwards to an appropriate specialist. C also raised concerns about the general treatment that they received from when they presented with a lesion on their left leg. The practice had acknowledged that there was a delay in diagnosing C’s DVT. However, there remained uncertainty regarding when the practice should have diagnosed a DVT or explored the possibility of this diagnosis.

We took advice from an independent GP adviser. In respect of the DVT, we found that this was a more difficult case of DVT to diagnose. However, there were signs that the practice unreasonably missed. C attended a consultation after they had been on a flight. We found that, from this point onwards, there was an unreasonable failure to fully take into account risk factors and symptoms pointing to an alternative diagnosis of DVT. There were also missed opportunities to carry out appropriate investigations that would have supported or ruled out such a diagnosis. We considered that there was less certainty over whether the DVT was present prior to C’s flight. We upheld this complaint.

In respect of the more general care of C’s leg, we found that this was initially of a good standard. However, this became less reasonable as the months went on and C’s symptoms persisted. We found that, at a certain point, the practice were not treating C’s symptoms proactively. We also considered an apparent absence of a dermatology referral, despite C’s records indicating that this was part of the treatment plan. For these reasons, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to diagnose or explore the possibility of DVT, for failing to treat C’s leg issues pro-actively after a period of time and for not following through on a referral to dermatology. 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:

• DVT should be explored as a possible diagnosis when relevant symptoms and risk factors are present, even when another diagnosis is considered more likely. Treatment for potential DVT should be provided in line with SIGN, NICE or other relevant guidance unless there is a specific reason not to do this. If a decision is taken not to follow relevant guidance, then the reason for this should be recorded.

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 relative (A) in relation to the nursing care and treatment that the board provided to A in hospital following orthopaedic surgery. A received nursing care in hospital before being transferred to another hospital for rehabilitation, where they died. In the second hospital, A was found to have a large wound on their foot and C complained that they had been unreasonably transferred with this.

We took independent advice from an experienced nursing adviser. We found that the wound care management that A received was unreasonable. We also found that it was unreasonable for the board to transfer A to another hospital without documenting this on the transfer document and without an adequate wound care management plan in place. We therefore upheld these complaints, although we found that the board had subsequently taken action to support improvement with regards to care rounding and pressure ulcer prevention.

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/information-leaflets.

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

• Adequate wound healing management plans should be in place for staff to follow prior to transferring patients to community hospitals.

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 standard of care and treatment provided by the board to their late parent (A) during two hospital admissions and the communication around this. C also complained about the way that A was discharged and when they felt that they were unfit to be discharged. A was hard of hearing and a non-English speaker. C said that the failings led to a great deal of mental and physical stress and A’s premature death shortly after the second discharge.

We took independent advice from a consultant physician specialising in medicine for older adults. We found that while aspects of the care and treatment were reasonable, there were failings. The board failed to communicate adequately in relation to A’s care and treatment. In particular, in relation to the seriousness of A’s illness and ensuring that A’s family understood that A was at the end of their life, and the lack of an in-person professional translator for A. Finally, we found that A was not discharged in a reasonable way on the second discharge home, that they should have been reviewed by a senior clinician and had all the relevant tests and investigations carried out and reviewed, and that on discharged, should have had all the required support from the community in place to meet their needs. We 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/information-leaflets.

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

• Patients and their family should be informed of significant treatment events.
• Patients should be discharged when they have been appropriately reviewed by a senior clinician and all relevant tests and investigations, have been carried out and reviewed.
• Patients should be discharged with all the required support from the community in place to meet their clinical needs.
• Patients who have a hearing impairment or do not speak English as a first language (or both) should have appropriate language support to enable them to fully access NHS services in the same way as patients who do not have barriers such as disability and language.

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 their adult child (A) received from the board during three admissions to hospital with non-epileptic seizures.

A is a prisoner and has a learning disability and autism. C is A’s welfare guardian. In terms of the guardianship order in place at the time relevant to the complaint, C was granted the power ‘‘to consent or withhold consent to medical or dental treatment and to require the Adult to comply with such treatment and to administer such medications as may be prescribed for the Adult’ and ‘To decide and approve the appropriate level of health and social care for the Adult".

C complained that they had not been appropriately involved in A’s care, despite holding the guardianship order. C complained that the board gave non-emergency treatment to A knowing that they were deemed to lack capacity to make that kind of decision.

We took independent clinical advice from a neurology adviser, who referred to the Adults With Incapacity (Scotland) Act 2000 (AWI), the code of practice for practitioners and relevant guidance.

We noted that A’s presentation was complex. We found that the board carried out appropriate investigations and provided reasonable care and treatment during each of A’s admissions. We did not uphold this aspect of C’s complaint.

We found that when C raised the matter of guardianship with the board during a telephone call, the board ought to have done more to explore this further. Guardianship paperwork should have been included in A’s records, with AWI paperwork completed appropriately for each admission. Whilst it was appropriate for the board to carry out emergency treatment without consulting the guardian, C ought to have been consulted in relation to all non-emergency treatment. We upheld this aspect of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings our investigation has identified. 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:

• Clinical and nursing staff are familiar with Adults with Incapacity legislation and guidance.

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’s adult child (A) was awaiting surgery for germ cell cancer when they became unwell and were taken to A&E. A was transferred to a ward where C raised concerns about the treatment that A was receiving. C felt that A was deteriorating and requested on a number of occasions that A be transferred to the High Dependency Unit (HDU) or another hospital. A number of reviews were undertaken and a transfer to HDU was agreed and actioned. Acute deterioration of A was noted and they were intubated and invasive mechanical ventilation began. It was also decided that A should be transferred to a different hospital. The transfer took place following the surgical removal of the catheter. A sustained a subdural haematoma (when blood escapes from a blood vessel, leading to the formation of a blood clot that places pressure on the brain and damages it), and developed multi organ failure and right and left ventricle failure. A died just over two weeks later.

C raised complaints with the board regarding A’s care and treatment, including concerns that information C had sought to provide staff, and requests that they had made about A’s treatment, had been ignored. The board’s response concluded that generally A’s care and treatment had been reasonable. C was dissatisfied with this and raised their complaints with us.

We took independent advice from a consultant emergency physician adviser. We found that a significant adverse event review (SAER) would have been justified in the circumstances. We advised the board of this and they indicated that they intended to undertake an SAER regarding A’s care and treatment. In the circumstances, we suspended our investigation whilst the SAER was undertaken. We became concerned about the time that was being taken to progress and finalise the SAER and when we began to progress the investigation again, the finalised SAER report was provided to C shortly afterwards. A later meeting led to a revised SAER report being provided.

We found that the conclusions in the revised SAER, which acknowledged specific actions in the assessment, care and treatment of A, had not been reasonable and upheld this aspect of C’s complaint. We found that the actions the board have taken, or have committed to taking, to address the learning points and areas for improvement were reasonable.

We found that the gathering of staff views, accuracy and initial failure to identify the need to conduct an SAER in the board’s investigation and review of their actions was not reasonable and we would normally expect the SAER process to take within the 24 working weeks from commissioning to final approval estimated in the relevant national framework. We considered that the time taken in this case was unreasonable and, therefore, we upheld C’s complaint about the board’s response to their complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that they unreasonably failed to initially identify the need to conduct an SAER into their actions regarding the assessment, care or treatment of A. 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:

• The board implement recommendations 1-7 found at Section 7 of the SAER report.

In relation to complaints handling, we recommended:

• The board take steps to ensure SAERs are undertaken when appropriate.

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.