Health

Summary

C, a support and advocacy worker, complained on behalf of their client (B) about the care and treatment provided to B's spouse (A). A experienced urological symptoms including blood in their urine and a number of infections. After a number of investigations, A was diagnosed with bladder cancer which had spread to their prostate. A died a short time later.

C raised a number of complaints and we agreed to investigate four main concerns: that the board failed to provide a reasonable standard of urological treatment following insertion of a catheter, the delay in diagnosing A’s cancer; poor communication with B and A, and A’s poorly managed discharge from hospital.

We took independent advice from a consultant urologist.

C raised concerns that A’s catheter had to be refitted a number of times, which was difficult to do and caused A pain and discomfort. The board explained that a catheter is commonly fitted after surgery and a permanent catheter was fitted due to A’s past urology history and difficulty in emptying their bladder. We found that whilst it was reasonable to insert a catheter, the reasoning behind the decision was poorly documented and that as A required a number of emergency admissions for catheter related issues, the board should have considered an emergency cystoscopy (a procedure that uses a tube to examine the bladder and the urethra) and TURP (transurethral resection of the prostate) and they failed to do this.

Whilst it is agreed that A’s case was complex and a number of investigations were required, we found that there was a delay in arranging a diagnostic cystoscopy following an emergency admission, a breach of the waiting time target for cancer referrals and a failure to recognise the significance of paraaortic lymphadenopathy (lymph nodes of an abnormal size) which contributed to the delay in diagnosis of A’s cancer. We accepted that had this delay been avoided, A’s outcome likely would have been the same, although their quality of life would have been improved.

With regards to communication, we did not identify any issue with the volume or frequency of communication with A. However we concluded that important medical details were overlooked or not explained clearly, such as A’s urological diagnosis and overall management plans.

Our investigation also concluded that whilst it was appropriate to discharge A home due to their condition being manageable with pain relief and antibiotics, there was a failure to ensure adequate pain relief would be available to A.

We upheld all four complaints and made appropriate recommendations for learning and improvement.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the issues highlighted in this decision. 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:

• That A’s case be reviewed at the local Morbidity & Mortality meeting with a view to identifying opportunities that were missed to progress A’s diagnosis and ways of ensuring similar delays do not affect future patients.
• That the board review the record keeping in A’s case and take steps to ensure their junior doctors and trainees are receiving adequate training in good medical record keeping and that senior clinicians are reminded of their responsibility to maintain sufficiently detailed records of discussions with patients and relatives.
• That the senior staff involved in A’s care be asked to reflect on the way that bad news was delivered on this occasion, and in general, with a view to ensuring they do so in as inclusive and compassionate a way as possible and with reference to the MDU guidance on breaking bad news.

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 the lead up to the delivery of their twin babies. One of the twins (A) was stillborn.

C complained that the board failed to provide reasonable care and treatment during C’s pregnancy. We took independent advice from a consultant obstetrician and gynaecologist (specialist in pregnancy, childbirth and the female reproductive system). We found that while many aspects of the care and treatment were reasonable, the omission of some key measurements and tests was unreasonable and did not accord with guidelines. This impacted on clinicians being able to reach a fully evidenced position on what care was appropriate. Therefore, we upheld this part of C's complaint.

C complained that the board failed to reasonably communicate the risks and options available to them. We found that the records indicated that the board reasonably communicated with C in relation to the risks and options available to them. Therefore, we did not uphold this part of C's complaint.

C complained that the board failed to reasonably investigate C’s concerns. We found that many aspects of the reviews which were carried out were reasonable. However, we found that the reviews failed to identify that the significance of the lack of the measurements being taken was unreasonable, leading to a delay in identifying learning that could be taken forward. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings as identified in this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informati on-leaflets.

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

• Where adverse event(s) occur the review should be thorough and identify all relevant learning from the event.
• Where it is considered that there are growth issues in relation to a fetus, appropriate investigations and tests, including measuring the pulsatility index as required, should be carried out in line with relevant national 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 complained that the board failed to provide them with reasonable care and treatment. C has a rare demyelination condition (an inflammatory condition that affects the brain and spinal cord) which impacts them both physically and mentally. C is also unable to see clearly and struggles to concentrate.

C complained about the care that they received from the board during two hospital admissions. In particular, that staff were unprofessional and unempathetic and became impatient and abrupt when C was unable to do as staff asked.

We took independent advice from a senior nurse. We found that there was a lack of communication and understanding of C’s cognitive impairment which resulted in staff not fully understanding the issues C was dealing with on a daily basis and the challenges their diagnosis presents. There was also a lack of appropriate care planning and a failure to complete all documentation and risk assessments. This led to a failure to provide reasonable emotional and psychological care to C whilst an inpatient, a poor patient experience for C and anxiety over future hospital care. Therefore, we upheld C's complaint.

In addition, we also found that the board’s response to C’s complaint was poor and did not demonstrate the learning or improvement required.

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:

• Documentation and communications regarding care needs should be highlighted at admission, with all relevant risk assessments completed reflecting accurate assessment and planning of care needs. Care plans should be person-centred to incorporate patients who have a cognitive impairment.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the Model Complaints Handling Procedures (www.spso.org.uk/the-model-complaints-handling-procedures). The board should fully investigate and address the issues raised and appropriately identify and action 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 complained about the care and treatment that their late parent (A) received whilst in hospital. A was admitted to hospital with light headedness, dizziness, and pain in the hip and leg. C had concerns about the board’s failure to consider A’s previous medical history, decisions made during surgery, communication, care provided, and what was recorded on the death certificate.

The board said that investigations into A's blood loss found no issues and that they planned to discharge A. However, due to further bleeding A was not discharged and required emergency surgery. A was made aware of the risks associated with the surgery. This operation was successful, however, a further procedure was required to remove a section of A's bowel. Due to further changes in A’s condition, the board moved A to palliative care.

We took independent advice from a consultant in intensive care and acute medicine, a general surgery consultant and a registered nurse. We found that A's care and treatment was reasonable. However, A's medical history was recorded incorrectly by medical staff, affecting the treatment plan, investigations, and diagnosis. We found that A's operations were carried out reasonably. However, the surgical team failed to examine A in person when consulted which was unreasonable. Overall, we considered that the care and treatment provided to A was unreasonable and upheld this part of C's complaint.

In relation to nursing care, we found that the care and treatment provided to A was reasonable. We also found that A's death certificate was not completed incorrectly. Therefore, we did not uphold these part's of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to take an accurate medical history on admission, there was a missed opportunity for the vascular team to identify the correct diagnosis during their review of A, the failure to consider a diagnosis of aorto-enteric fistula earlier, and particularly, once the CT scan findings were available, and the failure of the surgery team to review A in-person. 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:

• Accurate medical history should be established by clinicians and investigations, including CT scans, that are carried out should be critically reviewed when considering diagnosis alongside the history. Medical records should be viewed to establish/confirm the correct medical history.
• When asked, the surgical team should fully review the presentation and history of the patient. Where necessary the patient should be seen in-person.
• When a specialist review is requested such as vascular, the specialist team should fully review the presentation and history of the patient.

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 to the board about various aspects of the board’s care and treatment of their partner (A) and their communication with C and A during an inpatient admission covering the end of A’s pregnancy and the birth of their child (B) by caesarean section. The board accepted that a number of areas of communication had not been reasonable and apologised for this. The board explained what action would be taken to address these areas for improvement. The board also accepted that in a few specific cases, A had not received reasonable care but indicated that they considered A’s care and treatment had been reasonable overall. In response to a specific complaint from C, the board stated that A had not had sepsis (blood infection) or been treated for it during their admission. A few months later, however, the board wrote to C and stated that their labour had been complicated by sepsis.

We took independent advice from an appropriately qualified midwife. We found that, overall, A and B received good care and appropriate standards of treatment that were in line with relevant professional standards. Given this, and that reasonable actions to minimise recurrence were taken in relation to areas where the board had accepted care was not of an acceptable standard, and where communication could have been improved, we did not uphold the complaint that the board had not provided reasonable care and treatment to A.

We found that A had had sepsis during their admission and receive prompt and appropriate care. However, we considered that the board’s repeated altering of their position on whether A had sepsis, both minimised A’s experience and, potentially risked inadequate care and treatment responses being provided to patients with suspected sepsis in the future. We upheld the complaint that the board’s response inaccurately stated that A did not have sepsis and was not treated for sepsis during their admission.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that their response inaccurately stated that A did not have sepsis and was not treated for sepsis during their admission. 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:

• Relevant board staff have a clear understanding of the symptoms and diagnosis of sepsis and the actions to take in treating sepsis and suspected sepsis.

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 was concerned about a number of issues regarding their care and treatment, and that of their child (A), during their pregnancy, A’s birth and afterwards. C raised complaints with the board and were dissatisfied by their response. The board’s response accepted that there had been issues with aspects of the boards complaint handling and a number of issues with their communication, but did not indicate that the board considered that there had been any issues with C or A’s care or treatment.

We took independent advice from qualified advisers with experience of obstetrics, neonatology and midwifery (the medical specialisms for pregnancy, childbirth etc.). We found that, overall, C and A had received reasonable care and treatment from the board and that, where areas for improvement around communication had been identified, reasonable actions had been taken to address these. We did not uphold these part's of C's complaint. We noted that the board had accepted that C had been assigned to an incorrect consultant’s waiting list for a post-birth debrief and upheld this complaint. We also noted that the board had appropriately apologised to C for this. However, we considered that the board should have taken steps to minimise the possibility of a similar situation recurring in the future.

In considering the board’s response to C’s complaints, we found that there were specific areas where the board’s response and actions could have been improved. However, taking into account those areas for improvement in complaints handling the board had identified, the apologies provided to C and the specific circumstances of the time C raised their complaints, overall the board responded reasonably to C’s complaint. We did not uphold this part of C's complaint.

Recommendations

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

• Steps are taken to minimise the possibility of patients being assigned to incorrect consultant’s waiting lists for post-birth debriefs.

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 spouse (A) presented to A&E with neck pain. A was discharged home as it was noted that they were on a waiting list for an MRI scan, following an urgent referral by their GP to orthopaedics (area involving the musculoskeletal system). A was admitted to hospital four days later and advised that they were terminally ill with bladder cancer which had spread to the spine. A later died. C complained to the board that A&E did not consult orthopaedics or arrange further testing when A presented with continuing pain despite prescribed medication. The board’s response indicated that A was appropriately assessed by the A&E doctors and as A was waiting on an MRI, the discharge letter to the GP advised to follow up with the hospital where the MRI was being organised. The board said that the GP was best placed to expedite further care with the relevant team.

We took independent advice from a consultant in emergency medicine. We found that A&E carried out an appropriate assessment, including consideration of any red flags which warranted further investigation or onward referral. We found that as A had already been referred to the spinal team and had an MRI ordered it was reasonable not to investigate A further. We found that the board acted in accordance with NICE guidance in how they managed A’s care and treatment, which was reasonable. Therefore, we did not uphold the complaint.

Summary

C complained about the ophthalmology treatment (the branch of medicine that deals with the anatomy, physiology and diseases of the eye) that they were provided by the board. They were referred by a consultant (Doctor 1) for a second opinion from a corneal specialist. C complained that they should have been seen by a consultant (Doctor 2) but were instead treated by a junior doctor (Doctor 3). Additionally, C complained about the treatment provided by Doctor 3 and the decision to discharge them from the ophthalmology service.

We took independent advice from a consultant in ophthalmology. We found that it was clear that Doctor 1 intended a specialist to examine C and that this did not happen. Although it may have been reasonable for C to have been seen by a junior doctor in clinic, there should have been clinical oversight by Doctor 2, with direct input to C’s management plan. We found that it would have been good practice for the outcome of the consultation to be reported back to Doctor 1, copying the letter to the GP and C. Instead, the outcome was only reported to C’s GP. We upheld this complaint. We also found that Doctor 3 should have tested C’s eye pressure before prescribing fluorometholone (a mild steroid). We upheld this aspect of C’s complaint. Finally, we also found it was unreasonable for the board to discharge C from their ophthalmology service, when Doctor 1 had agreed to follow-up in one year. 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.
• When apologising to C, the board should address their treatment plan and communications in relation to their discharge.
• The board should offer C a further consultation with Doctor 1, given they had agreed to a follow-up consultation with C.

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

• Clinical staff ensure that they write back to the referring clinician, copying to the GP and patient.
• Eye pressure is tested, in accordance with good clinical practice, prior to FML being prescribed.
• Where a tertiary consultant to consultant referral is made, the consultant should be aware that the case is there for their specialist opinion and provide some direct input to their management plan.
• Where referrals are made for a second opinion, the patient is discharged back to the referring clinician.

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 practice had prescribed them with Hormone Replacement Therapy (HRT) for a period of approximately four months despite knowing that they were trying to conceive. C said that they had subsequently attended a fertility clinic and were advised by a specialist that HRT would have a negative impact on their fertility. The practice identified learning and improvement from C’s complaint. They apologised to C for the frustration and distress caused to them by their experience.

We took independent advice from a GP adviser. We found that it was unclear from the medical records if the prescription of HRT was fully discussed with C to ensure that they understood the implications on their fertility and general health. We found that it was unreasonable for the practice to have prescribed C with HRT in the absence of their clear informed decision. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the prescription of HRT in the absence of their clear informed decision. 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

C’s spouse (A) was provisionally diagnosed with torticollis (a condition in which the head becomes persistently turned to one side) by their GP resulting in a routine referral to orthopaedics (specialism in the treatment of diseases and injuries of the musculoskeletal system). A’s symptoms continued to worsen and their referral was upgraded to urgent. A had a telephone call with an orthopaedic consultant and an MRI scan was organised. The pain continued to intensify despite strong medication. A presented to the out-of-hours service and also to A&E with worsening pain in their neck. A was referred to the hospital by their GP and advised that they were terminally ill with bladder cancer which had spread to the spine. A later died.

C complained to the board with concerns about A’s initial referral to orthopaedics not being treated as urgent, for the delay for an MRI scan, for orthopaedics not being consulted by A&E and further testing not being arranged. C additionally complained about the lack of process for a patient to be moved up the list of clinical priority when presenting to A&E. The board’s response indicated that no red flags were raised in the initial referral, that the orthopaedic consultant organised an MRI scan after speaking with A and that the out-of-hours assessments did not identify immediate orthopaedic review was required. The response also noted that A&E noted a plan was in place for further investigation, that there was no emergency issue which required immediate referral and that the GP was best placed to expedite further care with the orthopaedic team.

We took independent advice from a trauma and orthopaedic consultant, a GP and a consultant in emergency medicine. We found that it was reasonable for orthopaedics to treat the original referral as routine, but it was unreasonable that there is no evidence of a clinical summary of the orthopaedic consultation, and thereby no evidence that red flags were explored. We upheld this aspect of the complaint. We found that it was unreasonable that a more detailed history and clinical examination was not undertaken at the out-of-hours consultations, especially of red flags. We upheld this aspect of the complaint. We found that it was reasonable that A&E did not refer A urgently to another speciality or arrange further investigation or immediate assessment. We did not uphold this element of the complaint.

We also found that the board failed to identify that a Significant Adverse Event Review should have been carried out and that their complaint response did not clarify that it was a joint response with a second board, resulting in a lack of clarity and transparency.

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:

• Orthopaedic telephone consultations should be recorded, including evidence that any possible red flag symptoms have been explored and considered.
• Patients should be examined thoroughly and a clear history should be taken which considers the presence or absence of red flag symptoms.
• When a relevant adverse event occurs, the board should promptly carry out an SAER to investigate the cause and identify any potential learning.

In relation to complaints handling, we recommended:

• Relevant staff should be aware of the requirements of the complaints handling procedures, particularly with respect to dealing with complaints which span more than one NHS board.

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.