Health

Summary

Mr C complained on behalf of his mother (Mrs A) about the care and treatment Mrs A received at the practice. Mrs A attended the practice complaining of flu-like symptoms and was prescribed a particular antibiotic. That evening she became nauseous and started vomiting. Mrs A's condition deteriorated and she was admitted to hospital three days later with dehydration and acute kidney injury. Mr C was concerned that the practice had prescribed a certain type of antibiotic to Mrs A despite her medical history and about the effect this had on her.

We took independent advice from a GP adviser. We found that Mrs A should not have been prescribed the particular antibiotic and that it was almost certain that this aggravated Mrs A's dehydration and acute kidney injury. Mrs A should also have been advised to stop taking other medication until the diarrhoea and vomiting had resolved. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failings around the prescription of the antibiotic. 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:

• All of the relevant healthcare professionals at the practice should reflect on this complaint and its findings in their next appraisal.

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 a change in his pain medication and said that he suffered significant pain as a result.

We took independent advice from a medical adviser. We found that the decision to change Mr C's pain medication was reasonable and that this was made following an appropriate and adequate assessment of his pain. We did not uphold the complaint.

Summary

Mr and Mrs C complained about the treatment Mrs C received both during and after her pregnancy. Mrs C felt unwell throughout her pregnancy with nausea, heartburn and abdominal pain. Mr and Mrs C reported her symptoms during phone calls to the midwife unit. Mrs C was advised to take pain relief and get back in touch if the pain worsened. When Mr and Mrs C attended the Victoria Hospital for their 20 week scan they were told there was no foetal heartbeat.

After delivery of the baby Mrs C had bloods taken, and tests from the placenta, but waited more than ten weeks to see a doctor to discuss the test results. After chasing up the results Mr and Mrs C were told that bloods had been lost, requiring Mrs C to return to the ante-natal clinic for further testing. She was subsequently told she tested positive for lupus (an autoimmune condition that affects the body's defences against illnesses and infections) and required further blood testing. Errors in the testing meant that Mrs C had to return to the clinic again. Each time she had to wait with pregnant couples and found this distressing. Mr and Mrs C felt the miscarriage could have been avoided if Mrs C had received better treatment. They complained that Mrs C's lupus should have been diagnosed sooner, and that the loss of their baby might have been avoided.

We took independent advice from a midwife and a consultant obstetrician (a doctor who specialises in pregnancy and childbirth). We found that the advice given to Mrs C each time she contacted midwives regarding her symptoms was reasonable. We did note, however, that Mr and Mrs C's account of the reported symptoms was not reflected in the records and we were unable to reconcile the two. We found that testing for lupus during pregnancy is unreliable because results may be falsely positive and that there were no clinical indicators for Mrs C to be screened prior to her miscarriage. We considered that the treatment Mrs C received during her pregnancy was reasonable and did not uphold this aspect of the complaint.

In relation to treatment after the miscarriage, we found that errors in the blood sampling were unreasonable. We noted that Mrs C had experienced a traumatic loss and that having to return to the ante-natal clinic several times to have bloods taken added significant stress to her situation. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for these failings in their care, with an acknowledgement of the impact this had on them. 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 board should consider whether alternative arrangements could be offered for future patients who have experienced stillbirth or miscarriage, particularly if the procedure could be carried out elsewhere.

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 care and treatment he received at Dumfries and Galloway Royal Infirmary was unreasonable. Mr C has metastatic (cancer that spreads to other parts of the body) prostate cancer and chronic kidney disease. His complaint primarily concerned his nephrostomies (catheters inserted through the skin and into the kidneys to drain urine). He had experienced problems with catheterisations, and had infections and leaking. He complained that the reasons for his treatment had not been explained to him, especially in relation to his elective transurethral resection of the prostate procedure (a surgical procedure that involves cutting away a section of the prostate) and nephrostomies.

We took independent advice from a consultant urological surgeon (a clinician who treats disorders of the urinary tract). We considered that Mr C's initial treatment was reasonable. After catheterisation failed to improve his kidney function, nephrostomies were inserted on both sides. However, we were critical of the follow-up to the nephrostomies, particularly as Mr C was not offered direct access back to the clinical team at the hospital should any problems arise. We considered this especially important in light of subsequent frequent blockages which resulted in an A&E attendance. Taking into account Mr C's particular range of symptoms, we also questioned the decision to operate on Mr C's prostate to relieve obstruction, which carried a low chance of him being able to empty his bladder naturally. Therefore, we upheld this aspect of Mr C's complaint.

Mr C also complained that the board's communication was unreasonable. We found that there were shortcomings in record-keeping and could not find evidence that the board had provided Mr C with clear information regarding the prostate surgery and nephrostomies, or the impact that this would have on Mr C long-term. We noted that Mr C did not appear to have been given written information about who to contact in case of difficulties or concerns. 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 failings in treatment, with a recognition of the impact on Mr C's quality of life and apologise for the failings in communication. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The board should provide Mr C with a point of contact, to ensure he is seen promptly by a clinician with understanding of his condition in the event he experiences further problems with his nephrostomy.

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

• If possible, the terms of this decision letter should be shared with those clinicians who were involved in Mr C's care, in a supportive manner, with evidence they have reflected on this. An anonymised version of this letter should also be shared with urology clinicians employed by the board to carry out treatment of this nature, with a reminder of the importance of good record-keeping. The board should consider the presence of urology nurses during consultations, which may be of value.
• Clinicians providing this treatment should ensure that appropriate information is supplied at the time of discharge. They should plan ahead for exchange of nephrostomies and ensure patients have a forward plan.

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 about the care and treatment she received during two admissions to Galloway Community Hospital. Mrs C was admitted with abdominal pain and she was suspected to have sepsis (blood infection). We took independent advice from a consultant in acute medicine. We found that during Mrs C's first admission, there was a delay in administering her antibiotics and that she should have been given intravenous fluids (fluid through a drip). We also found that during both admissions there was an unreasonable delay in investigating and establishing the source of her underlying infection. We upheld this aspect of Mrs C's complaint.

Mrs C also complained about the follow-up care she received from the board in response to her ongoing abdominal pain. We took independent advice from a consultant colorectal surgeon (a specialist in conditions of the colon, rectum or anus). We found that reasonable steps were taken to investigate Mrs C's condition and she was given appropriate advice that surgery would not be appropriate treatment for her. We did not uphold this aspect of Mrs C's complaint. However, we gave feedback to the board about the potential benefit of offering out-patient follow-up for patients with complex and unresolved conditions like Mrs C.

Finally, Mrs C complained about the board's handling of her complaint. We found that there was a failure to update Mrs C during the board's investigation, which the board had acknowledged and apologised for. We also found that the board failed to investigate and respond to all aspects of Mrs C's complaint. Therefore, we upheld this aspect of Mrs C's complaint and we made further recommendations in relation to this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the unreasonable failings in her care and treatment and for the failings in the board's complaints handling. 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:

• When a patient is suspected to have sepsis, they should receive appropriate treatment, including the prompt administration of antibiotics.
• If a patient's diagnosis is unclear, there should be a system in place so medical staff can seek advice or a prompt review from a consultant.

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 www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs.

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 her mother (Ms A) received at the Golden Jubilee National Hospital. Ms A had bilateral uniportal video-assisted thoracoscopic surgery (VATS - a type of 'keyhole' surgery where only very small cuts (incisions) are made to the body). Ms C was concerned about the length of time Ms A had to wait for surgery, that surgery was not the appropriate treatment and that further investigations were not carried out before the surgery.

We took independent advice from a consultant in thoracic surgery (also known as cardiothoracic surgery. It is the field of medicine involving the surgical treatment of organs inside the chest). We found that all investigations necessary for surgery were performed according to the relevant guidelines and that the type of surgery was reasonable and performed within a reasonable length of time. We did not uphold Ms C's complaint.

Summary

Mr C complained about the treatment which he had received at Ninewells Hospital. Mr C said that he had problems with a left-side perianal abscess (a local accumulation of pus that forms next to the anus, causing tenderness and swelling) and that he was taken to theatre for surgery. When Mr C recovered from the surgery he noted that there was a dressing on the right side of the anus and that the abscess on the left side was still present. Staff assured Mr C that the surgery had gone ahead as planned. Mr C attended his GP a few days later and the GP confirmed the abscess on the left side was still present. Mr C felt that the board staff had operated on the wrong side of his anus.

We took independent advice from a colorectal (bowel) surgeon and a consultant radiologist (a specialist in the analysis of images of the body) and found that Mr C's records showed there was some confusion over the position of the abscess. Examination prior to surgery showed the problem area was identified on the left side and although the doctor who conducted the examination was present at the operation, surgery was carried out on the right side. The doctor did not raise their concerns with the operating consultant. We also found that international guidance states that to reduce the possibility of surgery being performed at the wrong site then the planned site should be marked. This did not happen in Mr C's case and although there was an area of concern on the right side, the area complained about by Mr C was on the left side. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for performing perianal surgery on the wrong side of the anal canal. 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:

• Staff should ensure that prior to surgery the appropriate site is marked to reduce the possibility of carrying out surgery on the wrong site.
• Staff should be reminded that if they feel that surgery is about to be performed at the wrong site that they inform a senior clinician.

Summary

Mr and Mrs C complained that the board unreasonably failed to maintain the air system at the neonatal unit at a hospital in their area. They said that the air system failed and their baby, who was born prematurely and was dependent on air/oxygen, had to be moved to a hospital in a second board's area and died there instead of the hospital in the board's area. Mr and Mrs C raised various concerns, including questioning the board's account that there had been no similar failures with the air system previously.

The hospital's air system includes two dryers (dryer 1 and dryer 2) which remove contaminants and moisture from the compressed air. When one dryer is in use, the other is set as a back-up dryer. The treated air is sent to the medical and surgical terminals within the hospital.

We found that at the time of events in question, services within the hospital began experiencing intermittent drops in air pressure. The problems were caused by the failure of dryer 2. The hospital activated contingency plans and began using air cylinders. The fault with dryer 2 was repaired five hours later, but recurred after seven hours and neonatal services took the decision to transfer babies to other hospitals. The fault was subsequently repaired.

We found that there was an incident 14 months before the events in Mr and Mrs C's case, in which dryer 1 failed, but there was nothing to suggest this previous fault itself was connected with the issues with dryer 2. However, it was clear that the board were not able to carry out all of the works needed to dryer 1, which meant that the air system was less resilient at the time the fault in dryer 2 occurred (and had been so for approximately 14 months).

The board offered an explanation for the time period taken to finalise the repairs to dryer 1, and the steps that they took to stock additional air cylinders during this time (increasing their supply fivefold) to mitigate the risk of a fault. However, given that the air system supplied air to the whole of the hospital, including the neonatal unit, we were concerned that it took such an extensive period of time to repair the fault to dryer 1; and that the board did not undertake any formal written risk assessment for having a dryer with an intermittent fault as the backup dryer, after the decision was made to operate the system this way.

Therefore, we upheld the complaint. In addition, we considered that in their response to Mr and Mrs C's complaint, the board did not fully address Mr and Mrs C's concerns and that they should have provided more information on the events in this case and the action that the board was taking in response to these.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for failing to undertake a formal written risk assessment for their air system and for failing to respond to the complaint appropriately. 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:

• Any potential threats to a hospital wide operational system such as the hospital's air system should be formally risk assessed and documented. There should also be a clear process for reporting and signing off the risk assessment.

In relation to complaints handling, we recommended:

• Complaint responses should fully address the concerns raised and provide the complainant with all the relevant information held on the matters complained about.

Summary

Mr C complained about the actions of a court appointed psychologist who interviewed him after he had been convicted of an offence.

In their response to the complaint the board set out the reasons why the court decided to appoint the psychologist. They also explained that specific information was required from Mr C so that the psychologist could prepare a report for the court, prior to Mr C being sentenced.

We found that the board investigated the complaint and clearly explained why the psychologist had to ask for the information. Therefore, we did not uphold this complaint.