Health

Summary

C complained about the care and treatment of their adult child (A) following A’s admission to hospital. A had a long standing, complex medical history including two kidney transplants and kidney cancer, and A died during their admission. In particular, C complained about A being prescribed Dapsone for a skin infection without discussion with A’s Renal Consultant and also that the Respiratory Team did not review A in the days prior to A’s death. C also complained that the board had failed to communicate in a reasonable way, in that critical information relating to A’s care had not been passed on between clinical teams or shared with the family.

The board said that A’s renal disease did not contraindicate Dapsone which was frequently used following renal transplantation. The progressive respiratory reaction which A suffered would be a very rare side effect. The board said that Dapsone was appropriately discussed with A and prescribed, with no known lung or kidney-related risks in standard guidance. The Renal Consultant was informed and raised no concerns. The board acknowledged that the communication between clinical teams as documented in the medical records was open to interpretation and that this aspect of the complaint could have been better addressed in the formal complaint response.

We took independent advice from a Renal Consultant and a Respiratory Consultant. We found that the clinical care and treatment was reasonable, and in keeping with normal practice. There was no requirement to seek advice from A’s Renal Consultant about the prescription, but they were aware of it and had no concerns. The side effect that A experienced is extremely rare such that the effect and outcome could not have been foreseen. We found that the Respiratory Team were appropriately involved where required and that the care provided was reasonable. We did not uphold this complaint.

However, we found that the board had failed to communicate in a reasonable way and that communication fell short of a reasonable standard in relation to the involvement of the Respiratory Team. We also found that there were complaint handling failings. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for the failings in communication. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/meaningful-apologies" www.spso.org.uk/meaningful-apologies .

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

• Clinicians should clearly and consistently communicate to patients and their families, as appropriate, the roles of different teams and relevant clinicians involved. If staff agree to arrange review from another team this should be followed up to ensure it happens, or an explanation given as to why this is not necessary.
• Where an adverse drug reaction causes or contributes to a death, this should be reported to COPFS in line with their guidance.
• Serious adverse medicine reactions should be reported in line with the Yellow Card Scheme guidance.

In relation to complaints handling, we recommended:

• Where failings are clear from the evidence available, organisations should openly acknowledge and apologise for these. The board should ensure that complaint responses are accurate and based on the available evidence and relevant guidance. 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 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 that their late partner (A) received from the board’s gynaecology and oncology services at Glasgow Royal Infirmary. A was admitted to hospital, diagnosed with liver cancer, given two months to live and died. C also complained about the board’s handling of their complaint.

We took independent advice from a consultant gynaecologist and a consultant oncologist. We found that there appeared to be no evidence that A had any follow-up appointments with the board until 1 year and 11 months after completion of their cancer treatment, contrary to the west of Scotland cancer network guidelines. We noted that the board had acknowledged that A had a long wait for their gynaecology follow-up appointments, their cancelled appointments were not reappointed within a month, and they had to chase for appointments. We noted that the board had apologised for these failings and indicated that they were taking remedial action to address this. Given the board’s failure to follow the guidelines and their repeated cancellation of A’s gynaecology appointments, on balance, we upheld the complaint.

C also said that the board’s response to their complaint did not give them any option to ask for clarification or to challenge the response. We found that the board failed to follow the NHS Model Complaints Handling Procedure and advise C that a named member of staff was available to clarify any aspect of the response. We, therefore, upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failing 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:

• The board should follow the WOSCAN CMG’s recommendations on follow up appointments for patients with endometrial cancer.

In relation to complaints handling, we recommended:

• In their complaint responses, the board should advise complainants that a named member of staff is available to clarify any aspect of the response. 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 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 provided to their parent (A). A had dementia and had suffered several falls. C complained that the board failed to reasonably investigate A’s fall and that they failed to reasonably consider carrying out a Significant Adverse Event Review (SAER).

We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly) and a registered nurse. We found that the board should have identified ambiguous and confusing language was used to describe A’s fall in its investigation. It should also have established that the fall was unwitnessed. We upheld this complaint.

In relation to a SAER, the board were able to demonstrate that they had followed the guidelines in place at the time for determining if an SAER was required. In the period following the incident, local guidelines governing the holding of an SAER were superseded by national ones. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for failing to provide a clear explanation about A’s fall at the time, or in the subsequent complaint investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/meaningful-apologies" www.spso.org.uk/meaningful-apologies .

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 in A&E, and the subsequent handling of their complaint by the board. C initially attended the A&E with vomiting, diarrhoea and abdominal pain. Although C and their partner raised the possibility of appendicitis, this was dismissed. C was diagnosed with gastroenteritis and discharged without a full abdominal examination or review by a senior clinician. The following day C’s condition deteriorated, and C was found to have a ruptured appendix and septic shock, requiring emergency surgery, ventilation, and a prolonged hospital stay.

We took independent advice from an Advanced Nurse Practitioner. We found that the care and treatment that C received was unreasonable because a thorough abdominal examination was not carried out by a senior decision maker and documented to exclude appendicitis as a differential diagnosis, prior to discharging C. It was also unreasonable that the board did not initiate an Adverse Event Review at an earlier stage. We upheld C’s complaint.

Regarding complaint handling, we found that the board failed to provide a response addressing all issues raised and did not give C a revised timescale for their delayed response, contrary to the NHS Model Complaints Handling Procedure. We upheld C’s complaint about the board’s complaint handling.

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:

• When a relevant adverse event occurs, the board should promptly carry out an Adverse Event Review to investigate the cause and identify any potential learning.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaints investigators should fully investigate and address the key issues raised. 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 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 standard of care provided to their parent (A) following a scan carried out after A’s diagnosis of breast cancer. After speaking with a consultant, A and their family understood that A had metastatic stage 4 cancer. They made significant life changing decisions based on this understanding.

A later sought their own second opinion as they considered that the interpretation of the scan had not taken into account a previous injury. The board performed another MRI scan which showed no convincing evidence of metastatic disease.

We took independent advice from consultants in radiology and oncology. While the initial interpretation of the scan was reasonable, we found that there was a failure to arrange a further review of the scan and obtain a second opinion after A raised doubts about the diagnosis. The board also failed to issue an amended report of the scan in light of A’s trauma history, and there was an unreasonable standard of communication around the scan and the related complexities of A’s diagnosis. Therefore, we upheld the complaint.

When we initiated our investigation, the board reflected on their complaint handling which we welcomed. They apologised for the distress, noted their failings and set out the action they planned to take to address these issues. In light of this, we made no recommendations but asked the board to provide evidence of the actions taken.

Summary

C, an independent advocate, complained on behalf of B, about the standard of medical and nursing care provided to B’s late spouse (A) by the board following a liver cancer diagnosis.

B complained about A’s diagnosis, noting that A was initially seen to have one lesion and to be suitable for a liver transplant, however, three months later multiple lesions were found and A was no longer seen as a viable candidate. B also complained of subsequent delays in cancer treatment and that the nursing care provided to A was below a reasonable standard, including failures to prevent an unwitnessed fall.

B said that communication from clinicians regarding A’s diagnosis, prognosis and treatment was lacking detail and infrequent, and that the board’s stage two complaints response was inaccurate.

We took independent advice from a consultant hepatologist (specialist in diseases of theliver, gall bladder, bile ducts and pancreas) and a registered nurse adviser. We found that A’s diagnosis and treatment were reasonable and did not consider that multiple lesions had been unreasonably missed initially. We did not uphold this aspect of the complaint.

However, we found that there had been failings with respect to communication, particularly when A’s care was transferred to a specialist transplant unit outwith the board. We also found that the nursing care provided was unreasonable, including failings to record comfort, pain, and personal care, and in relation to delirium, falls prevention and risk assessments. Lastly, we noted inaccuracies in the complaints responses provided to B. As such, we upheld these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B 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:

• Patients (and where appropriate their family / carers) should be kept fully informed in a timely manner about their diagnosis, prognosis, and treatment.
• Patients who are admitted to hospital should have appropriate risk assessments carried out.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaint responses should be accurate, clear, and supported by the relevant 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 provided by the board in relation to a cancerous lesion (squamous cell carcinoma, SCC) on their middle finger. C received cryotherapy for eight months but at the end of the treatment, the lesion was worse. C said that they should have been reviewed by a consultant sooner when it became apparent the treatment was unsuccessful and they would have chosen surgery at the outset if they had been told of alternative treatment options. As a result of the failings, C said that they developed a more serious lesion.

We took independent advice from a consultant in dermatology. We found that the standard of medical care provided was not reasonable in that the uncertainty of diagnosis was not communicated to C and treatment options were not fully considered and discussed. Additionally, cryotherapy treatment was continued without consultant review for an extended period and the GP’s re-referral of C was downgraded to ‘routine’. 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/meaningful-apologies.

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

• There should be careful discussion of options in the light of equivocal histology reports. This is typically a multidisciplinary team meeting (MDT). Diagnostic uncertainty or limitations should be shared with patients as part of a full discussion of treatment options.
• It is good practice for images to be incorporated into the patient record in the patient lesion pathway.
• There should be closer supervision of the nurse-led cryotherapy service.

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 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.