Health

Summary

Ms C's brother (Mr A) collapsed at home and an ambulance was called. It took around 45 minutes to arrive and, upon arrival, the crew found Mr A to be in cardiac arrest. He was pronounced dead shortly after. Ms C complained about the failure to send assistance to Mr A sooner, including that a community first responder (CFR) was not used. She also complained that the crew did not carry out cardiopulmonary resuscitation (CPR).

The Scottish Ambulance Service (SAS) responded to Ms C's complaint and then carried out their own internal clinical review with the ambulance crew to enable further reflection on the incident. SAS identified that the call had been inappropriately downgraded from a cardiac arrest to chest pain category. It was identified that a satellite navigation failure contributed to the delay in the ambulance arriving. It was also noted that a CFR was not showing as available due to software and systems issues, and was therefore not used.

We took independent clinical advice which agreed with some of SAS's findings. We noted that there were differing interpretations of the guidelines on when CPR should or should not be attempted. We found that the crew should have taken steps to establish all the available facts in order to fully inform their decision-making in this regard. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C that SAS were unable to utilise a CPR due to software/systems issues; that a satellite navigation system failure added to the ambulance response time; and that the ambulance crew failed to take steps to determine with more accuracy the facts of the cardiac arrest, in order to support the decision-making process prior to the cessation of resuscitation. 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:

• Steps should be taken to establish all available facts before taking the decision to terminate CPR, including asking relevant questions of family/friends. SAS should give consideration to ways in which aide memoire/checklists might be used to support clinical decision-making during resuscitation attempts.
• There should be confidence that control dispatchers are able to identify logged on CFR when checking for available resources.
• Call handlers should be familiar with Medical Priority Despatch System (MDPS) protocol and should ensure calls are accurately categorised.
• SAS should confirm they have a suitable organisational back-up system in place for directing crews to an incident in the event of a failure of satellite navigation systems.

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 practice after she was diagnosed with secondary breast cancer in her lymph nodes. She had been attending the practice with a number of separate symptoms including a drooping right eye, fatigue; pain in her right shoulder, a rasping voice, vomiting and fainting. She did not consider that these symptoms were ever properly considered as a whole, which may have prompted an earlier diagnosis. She was also concerned that there was a failure to appropriately ready her for the diagnosis, claiming she had been repeatedly reassured her symptoms did not point towards a serious diagnosis.

We took independent advice from a GP. We found that the symptoms were relatively common and were not suggestive of a cancer diagnosis. Given this, we considered that the practice's communication with Ms C had been reasonable. We did not uphold either of Ms C's complaints.

Summary

C underwent an operation to their eye at Ninewells Hospital. C considered that they were not provided with information about the medical reasons why an operation to their eye was necessary. There were complications following this surgery. C raised concerns about what happened and why there was a failure to involve them in discussions about subsequent treatment options. C was concerned that the operation was not necessary and put them in a worse position than they had been before the operation.

We took independent advice from an ophthalmologist (a specialist in the branch of medicine concerned with the study and treatment of disorders and diseases of the eye). We considered that the operation was necessary. However we found that:

there was no evidence in the clinical notes that C was informed about the reasons for their options for treatment when they attended the hospital;

there was no evidence in the clinical notes that the risks of surgery were specifically discussed with C. There were the usual risks of bleeding and infection, but in this case there were also extra risks;

when C presented with severe pain after the initial eye surgery they should have been able to attend Ninewells Hospital within the same day to obtain advice from the surgical team who carried out the operation. We found that there was an unreasonable delay in C obtaining definitive treatment from the hospital after they suffered a complication from the original surgery; and

there was an unreasonable failure to include C in any subsequent discussions about treatment options after the first operation.

We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for an unreasonable failure to provide them with information about the medical reasons why an operation to their eye was necessary; an unreasonable failure to provide them with information about possible complications following surgery and alternatives to the planned operation; an unreasonable delay in them obtaining prompt advice from the surgical team at Ninewells Hospital when they developed severe pain following the eye surgery; and an unreasonable failure to include them in any subsequent discussions about treatment options after the first operation. 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:

• Information about reasons for treatment, possible complications, and alternative management of non-intervention should be provided to and discussed with the patient prior to consent for treatment being obtained.
• Patients undergoing eye surgery at Ninewells Hospital should have access to a reliable pathway where they can obtain advice urgently in the event of postoperative problems.

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 to us on behalf of his late father (Mr A) who was diagnosed with, and subsequently died as a result of, septic arthritis (a serious type of joint infection). Mr C complained that the board failed to provide reasonable care and treatment in relation to Mr A's shoulder pain at a minor injuries unit (MIU) consultation and at a physiotherapy (the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery) consultation. Mr C also complained that the board did not refer Mr A for x-ray or to orthopaedics (conditions involving the musculoskeletal system). Mr C considered that this had caused delays with Mr A being ultimately diagnosed with joint sepsis.

We took independent advice from an emergency nurse practitioner and from a consultant physiotherapist. We found that the board's consultations with Mr A were unreasonable in that Mr A should have been referred for an x-ray at the MIU consultation and that Mr A's presenting symptoms were not appropriately assessed at the physiotherapy consultation; it also had not been demonstrated that infection had been ruled out as a differential diagnosis. We found that Mr A should have been referred for further investigations/assessment at the physiotherapy consultation. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologiseto Mr 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/information-leaflets.

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

• Patients should be referred for x-ray as appropriate. Patients presenting for physiotherapy should be appropriately assessed in line with recommended clinical guidelines, taking in account their presenting symptoms, and this should be 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 care and treatment his partner (Mr A) received from the board. Mr A was diagnosed with Functional Neurological Disorder (FND, a condition in which patients experience neurological symptoms such as weakness, movement disorders, sensory symptoms and blackouts) and depression. Mr A was seen by a consultant neurologist (a specialist in the diagnosis and treatment of disorders of the nervous system) at a neurology clinic. Mr C complained about the length of time it took to arrange appointments for the joint Functional Neurological Clinic (the joint clinic); the communications surrounding these appointments; the changes in medication and the lack of subsequent review. Mr C also complained about the length of time it took the board to respond to the complaint.

We took independent advice from a consultant psychiatric adviser. We found that, whilst the clinic appointment waiting time was not ideal, there was no unreasonable delay in the circumstances. We also did not identify any unreasonable delays in Mr A's follow-up appointments being arranged. Whilst there was some communication shortcomings, we did not consider that these amounted to unreasonable failings. However, given there was no record of a discussion with Mr A about the potential adverse effects of increasing his medication, on balance, we upheld this complaint.

We also found that the board had accepted that the delay in responding to the complaint was excessive and that they had apologised accordingly. We upheld this aspect of the complaint but made no further recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for failing to demonstrate that discussion took place with him regarding the potential risks of adverse effects when increasing his medication dosage. 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 expected benefits as well as the potential burdens and risks of any proposed investigation or treatment should be explained to patients in line with General Medical Council guidance on consent.

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 arrived at Ninewells Hospital's emergency department by ambulance. After an initial assessment C was transferred to a mental health unit. C complained about the treatment provided at both locations. We took independent psychiatric advice.

We found that the treatment provided at Ninewells Hospital was reasonable, C was appropriately assessed and managed, with an appropriate referral to psychiatric services and appropriate steps taken to maintain C's safety. We did not uphold this aspect of the complaint.

We found the treatment provided at the mental health unit was also reasonable. A thorough examination of C was undertaken and during C's admission adequate monitoring and care of C was provided. We did not uphold this complaint.

Summary

Mr C, who had a previous history of repeated sinus infections, attended the day surgery unit at St John's Hospital for planned septoplasty surgery (corrective nose surgery). He was prepared for surgery by a nurse but Mr C was then reviewed by a doctor who decided that surgery was not required at that time and that Mr C could be discharged home with nasal capsules and would be reviewed at a later date. Mr C said that it was unreasonable that the doctor had overruled a previous consultant, who deemed that surgery was required, and that he was prescribed capsules which had not been effective in the past.

We took independent advice from an ear, nose and throat surgeon. We found that it is not unusual for planned surgery to be cancelled on the day of surgery. Clinicians who may have not seen the patient previously routinely review the symptoms reported and may determine that the surgery is cancelled or that alternative surgery should proceed instead. We did not uphold Mr C's complaint.

Summary

Miss C attended the Royal Infirmary of Edinburgh A&E having cut her lower right leg. The wound was treated with wound closure strips and a dry dressing. Miss C complained that it was not appropriate to treat her wound with strips and that they should have been sutured as she developed an infection and required further treatment. The board explained that wounds on the lower leg take longer to heal, are more prone to infection and it is unlikely suturing would have resulted in a different outcome.

We took independent advice from a medical adviser. We found that the use of wound closure strips can be as effective as sutures in cuts. There was no evidence to suggest that the treatment provided was unreasonable and it would not be possible to determine whether the wound would not have become infected if it had been stitched. Therefore, we did not uphold the complaint.

Summary

Mrs C complained that the reporting of x-rays taken of her knees was unreasonable. Mrs C was referred by her GP for an x-ray as she had been suffering from pain in her knees for over a year and her GP thought that she might be experiencing the onset of arthritis (a disease causing painful inflammation and stiffness of the joints) . Knee x-rays were carried out and Mrs C's GP later advised her that the x-rays showed no signs of arthritis. However, Mrs C subsequently attended a private hospital and was advised that x-rays did show early onset arthritis and swelling in both knees. Mrs C stated that the x-rays from the board had not been looked at properly.

We took independent advice from a consultant radiologist (a specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found no evidence that the reporting of Mrs C's knee x-rays had not been reasonable but the images taken allowed for different interpretations and did not give a clear enough picture to result in a definite arthritis diagnosis. Therefore, we did not uphold the complaint.

Summary

C complained about the care and treatment they received from the practice. C had a history of back pain and attended a consultation at the practice. During the consultation, the GP discussed a number of pain relief medications with C and a prescription was made.

Approximately three weeks later, C presented to a hospital and received emergency treatment for cauda equina syndrome (a rare and serious neurological condition that affects the bundle of nerves (cauda equina) at the base of the spine). C raised concern that the practice missed signs of cauda equina syndrome when they attended the practice a number of weeks earlier. They were also unhappy with the treatment provided at the time.

We received independent advice from an appropriately qualified adviser. We found that an appropriate assessment was performed during the GP consultation. Having considered the accounts of C and the practice, we concluded that the practice did not miss red flags for cauda equina syndrome. We also considered that the discussion regarding medication and prescription were reasonable. We did not uphold C's complaint.