Health

Summary

Ms C complained that the care and treatment she received from the practice was unreasonable. Ms C attended the practice on a number of occasions complaining of a sore lump. She was referred to the treatment room (the treatment room is staffed by nurses who are trained and specialise in wound care) for assessment and management of a post-operative wound she had. Ms C also attended the hospital and was informed she had cellulitis (an infection of the deeper layers of skin).

We took independent advice from a GP. We found that the practice had assessed Ms C's wound, arranged an appropriate referral to the treatment room and arranged appropriate treatment. We did not uphold the complaint.

Summary

Mr C complained about the care and treatment he received from a number of different clinical areas provided by the board. In particular, Mr C raised concerns about the care and treatment he received while he was a patient of the Physical Disability Rehabilitation Unit, the treatment he received from occupational therapy and the treatment of his urine infections and acid reflux symptoms.

We took independent advice from a physiotherapist, an occupational therapist, a consultant urological surgeon and a neurologist regarding Mr C's concerns. We did not find any failings regarding the care and treatment Mr C received.

We did not uphold Mr C's complaint.

Summary

Miss C complained that the board had unreasonably delayed in diagnosing and treating her brother (Mr A)'s prostate cancer. We took independent advice from a consultant urological surgeon (a doctor who specialises in the male and female urinary tract, and the male reproductive organs).

We found that communication about Mr A's diagnosis and prognosis had been reasonable. However, we found that there had been an avoidable delay in diagnosing his prostate cancer, and as a result there had been a possible delay of six to eight weeks in staring his treatment. We upheld the complaint. However, we noted that the delay had no significant clinical impact on the disease progression or prognosis.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C and the family for the delays identified in this case. 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 presenting with signs or symptoms of prostate cancer should be referred to the local multidisciplinary team meeting as soon the diagnosis is suspected.

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

Mrs C complained that medical staff failed to diagnose her husband (Mr A) with urethral obstruction (a blockage that inhibits the flow of urine through it's normal path). Mr A presented to Royal Alexandria Hospital on a number of occasions with urology (the branch of medicine and physiology concerned with the function and disorders of the urinary system) problems, including difficulty urinating and passing blood. An X-ray was carried out which showed no kidney stones and tests confirmed no infection. He was discharged but attended several days later to the emergency department, unable to pass urine. He was examined, catheterised and discharged home with medication to relax the bladder neck. No follow-up appointment was arranged. Nine days later Mr A was admitted to hospital as he was unable to pass urine. Following further tests, and subsequent attendances at hospital with issues regarding his catheter, including treatment with antibiotics for infection, Mr A underwent a cystoscopy (bladder examination using a narrow tube-like telescopic camera) where a intra-urethral stone was extracted from the penis. Mrs C said that doctors did not take account of the symptoms Mr A had presented with and they failed to carry out basic checks. It was not until they sought private opinion that appropriate tests were carried our and the stone causing the obstruction was discovered.

We took independent medical advice from a consultant urologist. We found that on the initial presentations to hospital, physical examinations of the abdomen and genitals were not carried out, despite repeat presentation and reported symptoms indicating this should have occurred. Appropriate examinations, particularly of the penis when indicated, would likely have identified the presence of the stone. Medical and nursing staff did not adequately document and act on difficulties which were encountered in passing the catheter. We, therefore, upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the failure to carry out appropriate physical examination, escalate difficulties in catheterising, and to arrange for further assessment with flexible cystoscopy. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance .

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

• Emergency staff, when presented with blood in urine in the absence of infection, should recognise this requires urgent investigation.
• Relevant medical and nursing staff should be aware of the need to take a good history and perform appropriate genital examinations. Nursing staff should be aware of potential causes for difficulties in catheterisation and empowered to ask for support or abandon catheterisation if difficulties are encountered.

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

Ms C complained about the care and treatment she received at Princess Royal Maternity Unit and Queen Elizabeth University Hospital following the birth of her baby. Ms C complained about the appropriateness of a speculum (a metal instrument that is used to dilate an orifice or canal in the body to allow inspection) examination and had concerns whether an ultrasound had been carried out and reported properly. Ms C also complained that it took around three weeks for it to be identified that she needed surgical treatment for ongoing bleeding and retained products of conception, and about the lack of breast pump available and support given regarding expressing milk.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in pregnancy, childbirth and the female reproductive system) qualified in ultrasound, a consultant obstetrician and gynaecologist, and a midwife. We found that it was appropriate to perform the speculum examination and that the ultrasound had likely been interpreted accurately. Therefore, we did not uphold this aspect of Ms C's complaint.

We also found that subsequent investigations did not identify significant products of conception that required earlier surgical intervention. We further considered that there was reasonable evidence to reflect that advice had been offered regarding breast care and that it was not unreasonable that a breast pump was not available at the time of discharge. However, we noted that the board reflected on Ms C's concerns and acknowledged the benefit of improving their supply of breast pumps. We did not uphold this aspect of Ms C's complaint.

Summary

Mr C complained about the care and treatment that his late father (Mr A) received at Aberdeen Royal Infirmary and at a palliative care facility.

We took independent advice from a consultant head and neck surgeon, from a consultant clinical oncologist (cancer specialist) and from a nursing adviser. We found that the surgical and medical care and treatment Mr A received was reasonable.

However, we found failings regarding Mr A's nursing care. In particular, we found that Mr A was not prescribed two hourly position changes at Aberdeen Royal Infirmary and the palliative care facitility when he was at risk of developing pressure damage and that Mr A did not receive care in accordance with the board's policy on adults with tracheostomies (an incision in the windpipe made to relieve an obstruction to breathing). We upheld this aspect of Mr C's complaint.

Mr C also complained about how the board handled his complaint. We found that Mr C was not kept updated regarding a timescale for when he could expect to receive the board's complaint response and the minutes of a meeting. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not prescribing Mr A with care and comfort rounds every two hours; not delivering appropriate tracheostomy care to Mr A in accordance with the board's policy; the delay in responding to his complaint and that he was not kept updated. 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 at risk of developing pressure damage should be repositioned every two hours.
• Patients with a tracheostomy should receive care in accordance with NHS Grampian's Care of the Adult with a Tracheostomy Policy.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the model complaints handling procedure. The model complaints handling procedure and guidance can be found at https://www.spso.org.uk/the-model-complaints-handling-procedures .

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

Ms C complained to us about the care and treatment she received from the board when she was diagnosed with lung cancer. Ms C was told that the tumour in her lung had been visible in a CT scan she had several years earlier, which was taken to plan her radiotherapy treatment (a treatment using high-energy radiation) for breast cancer. Ms C complained that the lung tumour was not identified at that time or if it was, she was not offered any treatment. We took independent medical advice from an oncologist (cancer specialist). We found that CT scans for planning radiotherapy are not taken with enough detail to be used for diagnostic purposes. We also found Ms C's lung tumour was small and it could have easily been missed by a clinician who was not reviewing her CT scan for diagnostic purposes. We found it was reasonable that Ms C's lung lesion was not identified at that time and we did not uphold this aspect of her complaint.

Ms C also complained about the communication with her about her condition and treatment, leading up to her diagnosis of lung cancer. In particular, that Ms C was sent an appointment letter for a chest CT scan without being told the reason why she was being referred for a CT scan. We took independent medical advice from an acute medical consultant. We found that Ms C and her GP were not appropriately informed about the outcomes of investigations that had been carried out; and why there was a need to carry out further investigations into her condition. We upheld this aspect of Ms C's complaint.

Ms C also complained about the board's complaints handling. We found that the board did not keep Ms C appropriately updated during their investigation. We found that the board had failed to identify and respond to all aspects of Ms C's complaint; it was unclear what the conclusions of their complaints investigation had been; and they did not apologise to Ms C for failings they had identified. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings in their communication with her; and for failing to handle her complaint in a reasonable manner. 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 GPs should be appropriately informed about the outcomes of investigations and the need to carry out any further investigations.

In relation to complaints handling, we recommended:

• In line with the NHS complaints handling procedure, complaint responses should address all the issues raised and demonstrate that each element has been fully and fairly investigated; include the conclusions of the investigation; and include an apology where things have gone wrong. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets .

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

Mr C complained about the care and treatment provided to his child (Child A) during an admission at Royal Aberdeen Children's Hospital. Child A had a life-limiting condition, including heart and lung problems which made them susceptible to infection. Mr C complained that the hospital did not monitor Child A's blood gases frequently enough which led to an unreasonable delay in them being intubated. Mr C also complained that the hospital failed to accept a referral to the respiratory department. The board confirmed that they performed monitoring of Child A's blood gases when it was clinically indicated. They also confirmed they could not find any evidence of a formal written referral to the respiratory department.

We took independent advice from a consultant paediatrician (consultant specialising in the medical care of children). We found that appropriate monitoring of Child A's blood gases was performed, particularly for in a high-dependency unit setting. We did not find any evidence that the board failed to act upon a referral to respiratory. We did not uphold Mr C's complaints.

Summary

Mr C complained about the care and treatment he received from Aberdeen Royal Infirmary. Mr C had a nerve sheath tumour (a type of tumour of the nervous system) in his neck in an area known as the brachial plexus (a group of nerves that come from the spinal cord in the neck and travel down the arm. These nerves control the muscles of the shoulder, elbow, wrist and hand, as well as provide feeling in the arm). Mr C had surgery to remove the tumour. During the operation three nerves were found to be running through the tumour. All three nerves were stimulated electrically. One nerve made the deltoid muscle twitch and this nerve was preserved. The other two nerves produced no apparent muscle movement and were cut and removed with the tumour. This resulted in Mr C losing the use of large muscles in his arm.

We took advice from an otolaryngology (the study of diseases of the ear and throat) and head and neck surgeon and from a consultant neurosurgeon (a surgeon specialising in surgery of the brain and nervous system). We found that:

advice should have been sought from the Scottish Brachial Plexus Team prior to Mr C's operation

intraoperative neurophysiological nerve monitoring (IONM – where fine needles are placed in the target muscles and spontaneous muscle fibre electrical activity is continuously displayed on a screen as waves) should have been used during Mr C's operation

Mr C's nerves should not have been cut during the operation

Mr C was not referred to the Scottish Brachial Plexus Team within a reasonable amount of time following his surgery

the board failed to consider at an earlier stage whether an Adverse Event Review should have been carried out.

We upheld Mr C's complaint that the board did not provide him with reasonable care and treatment.

Mr C also complained that the board did not inform him of the risks of the surgery. We found that the board did communicate reasonably with Mr C about the risks of the surgery and therefore we did not uphold this aspect of Mr C's complaint.

Finally, Mr C complained that the board failed to handle his complaint reasonably. We found that:

the board's own complaint investigation did not identify the serious failings in the care provided to Mr C

there was a delay in responding to Mr C's complaint and he was not kept updated on the progress of his complaint or provided with a revised timescale for the response

the board's complaint response said that Mr C's reparative surgery took place on an incorrect date.

Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to seek advice from the Scottish Brachial Plexus Team prior to his operation; the failure to use IONM; cutting his nerves during the operation; the length of time taken to refer him to the Scottish Brachial Plexus Team after the operation; the delay in responding to his complaint and that he was not kept updated and; that the complaint response did not accurately state the date his reparative surgery took place. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance .

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

• The board should consider carrying out an Adverse Event Review where an event has occurred that could have resulted in harm (a near miss) or did result in harm to a patient.

In relation to complaints handling, we recommended:

• Complaint responses should contain accurate information.
• Complaints should be handled in line with the model complaints handling procedure. The model complaints handling procedure and guidance can be found here www.spso.org.uk/the-model-complaints-handling-procedures .
• The board's complaints handling system should ensure that failings (and good practice) are identified, and that it is using the learning from complaints to inform service development and improvement (where 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.

Summary

Ms C, a patient advice and support advocate, complained on behalf of her client (Miss A). She complained about the care and treatment Miss A received by the diabetology (diagnosis and treatment of diabetes) and neurology (diagnosis and treatment of disorders of the nervous system) services in relation to a range of symptoms including stomach pain, nausea, headaches, and dizziness and her diagnosis of Postural Tachycardia Syndrome (PoTS, an abnormal increase in heart rate that occurs after sitting up or standing).

We took advice from a consultant diabetologist and a consultant neurologist. We found that much of the care and treatment provided to Miss A was reasonable. However, there was a significant delay in follow-up from the neurologist, which the board had already agreed was unreasonable and apologised for. On this basis, on balance, we upheld this aspect of the complaint. However as the board had already apologised and taken action we did not make any recommendations on this point.

In relation to complaint handling, we found that there was a significant delay in the complaint being responded to by the board. Though we noted that the board had apologised for this, they had not given any explanation as to what caused the delay. They also did not evidence that Miss A was kept updated during the delays. We therefore made a recommendation to the board in relation to their complaint handling.

Recommendations

In relation to complaints handling, we recommended:

• Complaint responses should be provided in a timely manner, and where they will take longer than 20 working days complainants should be kept informed of the reasons for delays, in line with the model complaints handling procedure.

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.