Health

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.

Summary

Miss C, an advocacy worker, complained on behalf of Ms B that the board failed to provide her late mother (Mrs A) with reasonable care and treatment at Aberdeen Royal Infirmary and that staff at the hospital failed to communicate adequately with Mrs A's family about her care and treatment.

Mrs A had been admitted to the hospital's intensive care unit with respiratory failure where she died. Mrs A had suffered from a number of chronic illnesses. We took independent advice from a consultant in emergency medicine. We found that the care Mrs A received was reasonable and in line with current guidelines and good clinical practice. The evidence available showed that, ultimately, Mrs A's failure to respond to the treatment was because of the seriousness of her condition, and not the treatment itself. We did not uphold this aspect of the complaint.

In relation to communication with Mrs A's family, we found that it was clearly recorded in the clinical notes that on Mrs A's admission there had been a discussion with her family. It had been explained that there was a very real risk that Mrs A would not survive the admission and why performing cardiopulmonary resuscitation (CPR, where the heart and/or breathing is restarted if it stops) would not be in her best interest. However, other than this initial conversation, in general, communication with Mrs A's family was very poor. In particular, the decision to extubate Mrs A (to remove a breathing tube) should have been discussed with her family prior to this taking place. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms B and her family for the communication failures 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 families should be involved in the decision-making process where appropriate and should receive regular updates. This should be recorded in the clinical records.

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 that the board failed to communicate reasonably with him and his wife (Mrs C) about his child's (Child A) care and treatment. Mr C raised concerns about the timeliness and accuracy of medical advice; the failure to engage with Mr and Mrs C in a meaningful way; and a failure to obtain proper consent on a number of occasions.

We took independent advice from a paediatrician, and a paediatric surgeon with an interest in gastroenterology (the branch of medicine that deals with disorders of the stomach and intestines). We found that many aspects of communication had been reasonable, however, there was a lack of documentation regarding information given to Mrs C both prior to and following a endoscopy procedure (a medical procedure where a tube-like instrument is put into the body to look inside) carried out on Child A. The documentation was not in line with General Medical Council guidance on consent and protecting children and young people. We therefore upheld this aspect of Mr C's complaint.

Mr C also complained about the care and treatment provided to Child A. We found that the care and treatment provided was reasonable and did not uphold this aspect of the complaint.

Finally, Mr C complained about the board's handling of his complaints. Whilst we acknowledged that there was a significant volume of correspondence for the board to consider and respond to, we considered it clear that there were multiple occasions on which Mr and Mrs C's complaints were not handled in line with the appropriate complaint handling procedures. We considered that the volume of complaints made by Mr and Mrs C was partially as a result of complaints not being managed and responded to in an effective and timely manner; and that the board's failure to address correspondence correctly contributed to the breakdown in the complaints procedure. We also noted that the board had agreed at one point to issue a formal written apology about Child A being removed from the hospital without consent, but this apology had never been sent. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for the lack of documentation regarding information given to Mrs C both prior to and following the endoscopy procedure; the failure to handle the complaints in a reasonable and timely manner; Child A being removed from the hospital without consent; and the failure to issue an apology for this at the time. 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:

• Discussions with family members should be documented.

In relation to complaints handling, we recommended:

• Complaints should be handled in a reasonable and timely manner, and in line with the complaint 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.

Summary

Mr C complained about the lack of care which his wife (Mrs A) received from the Victoria Hospital Kirkcaldy. Mrs A had suffered from chronic knee pain for a number of years and had undergone episodes of arthroscopy (surgical technique to diagnose and treat problems in the knee joint) in the past. She requested further surgery but the surgeon decided that further surgery would not be of benefit and that she should continue with conservative treatment. Mrs A asked for a second opinion and another consultant discussed Mrs A's condition with the surgeon; it was again decided to continue with conservative treatment. Mr C thought that the decision of the surgeon was unreasonable and that they had influenced the decision from the consultant.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the decision by the surgeon not to offer further surgery was reasonable in the circumstances. If a patient still suffers from pain following repeated arthroscopic surgery, it would not be appropriate to continue with the surgical interventions when there is no notable benefit for the patient. We also found that it was not unreasonable for the consultant and the surgeon to have discussed treatment options for Mrs A and that the decision to persevere with conservative treatment was appropriate. We did not uphold the complaint.

Summary

Mr C complained about the care his mother-in-law (Mrs A) received at Victoria Infirmary Hospital. Mrs A has emphysema (a lung condition that causes shortness of breath) and has particular difficulty with her breathing when moving around. Mr C raised concern that when he made enquiries about Mrs A receiving ambulatory oxygen therapy (the use of supplementary oxygen during exercise and activities of daily living) it was unreasonably refused.

We took independent advice from a consultant physician in general and respiratory medicine. We found that it was reasonable for board staff to have reached the view that ambulatory oxygen was not indicated in accordance with guidance issued by the British Thoracic Society. We, therefore, did not uphold the complaint. However, we also considered that board staff should have offered Mrs A a second opinion and so we provided feedback to the board for reflection in this respect.

Summary

Miss C complained about the treatment which she received from a dentist. She said that she had attended the dentist over a five month period complaining of a sore tooth and that the dentist told her she required eight fillings. Miss C said that following the treatment she still suffered sensitivity and discomfort from the treated teeth and that when she attended another dentist she was told that the fillings were not required.

We took independent advice on Miss C's complaint from a dentist. We found that there was evidence from Miss C's x-rays that decay was present in her teeth and that treatment was required. Although Miss C had not reported problems with some teeth, it did not mean that there was no decay present and that, if the decay was not too deep, it is not uncommon for dentists not to record the depth of the decay. There was no evidence to substantiate the complaint that the dentist failed to provide Miss C with a reasonable standard of treatment. We did not uphold the complaint.

Summary

Ms C complained to us about the care and treatment she received at University Hospital Ayr. Ms C underwent total hip replacement surgery (a surgical procedure where a damaged hip joint is replaced with an artificial one) on both hips. Ms C raised concerns that the risks of each surgery were not communicated appropriately to her; there were failings in carrying them out, which caused her to experience pain and mobility issues; and her post-surgical care was unreasonable.

We took independent advice from a medical adviser who is a consultant orthopaedic and trauma surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). For both surgeries, we found no evidence of failings in carrying them out. We found that Ms C experienced recognised complications of total hip replacement surgery. We also found that Ms C's post-surgical care was reasonable. However, we found that there was no evidence Ms C was appropriately informed of the risks involved in each surgery during the consent process. Therefore, we upheld Ms C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings identified in the surgical consent process for both hip surgeries. 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 consent process should follow national guidelines. Consent should be taken, where possible, prior to the day of surgery. As part of the consent process, there should be a clear discussion of the risks and benefits (of having the surgery and not having the surgery) and of any alternative treatment options; and those discussions should be clearly 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.

Summary

Mr C complained about the aftercare and treatment provided to him following his knee surgery. Mr C underwent a full knee replacement and following the surgery he experienced difficulty with bending and positioning his knee, as well as extreme pain. Despite completing physiotherapy, hydrotherapy and intense exercises, the problem did not resolve.

The board acknowledged a rare complication had occurred following Mr C's surgery, however, they consider that there was no undue delay in addressing the stiffness in Mr C's knee and that it was dealt with in a reasonable timescale.

We took independent advice from a consultant orthopaedic surgeon (a medical expert who treats patients with problems in their muscles, bones, joints and other related structures). We found that the aftercare was provided promptly and that there was no unreasonable delay. The board were not provided the opportunity to carry out further investigations or treatment as Mr C chose to seek private treatment. The board acted reasonably by offering a second opinion, however the offer was declined. We did not uphold the complaint.