Health

Summary

Mr C complained that the board failed to appropriately assess and treat his chronic back pain. Mr C had received a recommendation for spinal cord stimulation (a pain management technique that involves the surgical implantation of an electrotherapeutic device onto the spinal cord) by a pain consultant from another area. The board explained to Mr C that they can only offer traditional spinal cord stimulation and not the high frequency type that was recommended for him as it was not available within Scotland. The board also said that Mr C did not meet the criteria for traditional spinal cord stimulation, which they do offer. In any case, any referral for further treatment would need to come from Mr C's local pain clinic which was not in Greater Glasgow and Clyde. Mr C was referred for a second opinion which confirmed agreement with the initial assessment and recommended a pain management programme. Mr C was dissatisfied with the board's decision and brought his complaint to us.

We took independent advice from a consultant in pain medicine. We confirmed that the treatment Mr C was seeking is not available in Scotland. We also confirmed it was correct to advise Mr C that any referral for further treatment would need to come from Mr C's local pain clinic. We concluded that the assessment of Mr C's pain was appropriate and the recommendation of a pain management programme was reasonable. Therefore, we did not uphold the complaint.

Summary

Mr C complained about the treatment his late wife (Mrs A) received at A&E of Aberdeen Royal Infirmary. Mrs A had collapsed at home, and had suffered a fatal heart attack. Despite attempts at cardiopulmonary resuscitation (CPR), Mrs A died. The board maintained that appropriate tests and investigations were carried out when Mrs A suddenly deteriorated and that the cardiac arrest could not have been predicted.

We took independent advice from an emergency department consultant. We found that the staff involved had carried out appropriate assessments and investigations into a possible cause for Mrs A's collapse at home and that she was being monitored appropriately. While the results of investigations were being waited on, Mrs A suddenly deteriorated and staff were unable to save her life. We did not uphold the complaint.

Summary

Ms C complained about the care and treatment her late sister (Ms A) received in Dr Gray's Hospital before her death. Ms A attended the emergency department in the hospital after striking her head. She had suffered a laceration (cut in the skin), which was glued shut, and she was then discharged. On the following day, she was admitted to the hospital with a high heart rate and shortness of breath. It was subsequently noted that Ms A was suffering from acute chronic kidney injury and chronic atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). She became unresponsive and was taken for a CT scan to check if her head injury was contributing to her loss of consciousness. Ms A died in the radiology department.

We took independent advice from an emergency medicine adviser and a consultant in acute medicine. We found that the standard of documentation for Ms A's presentation to the emergency department was poor. It was also unreasonable that she was not scanned in the emergency department before she was discharged, given her reduced level of consciousness and confusion; her headache; and the fact that she was on anticoagulant medication (medication to prevent blood clots). Further tests should have been carried out and her discharge from the emergency department was contrary to guidance. In addition, the advice given to her when she was discharged from the emergency department would have been challenging for Ms A to understand and retain. It was also surprising that, when she was admitted to hospital, Ms A was given increasing doses of beta-blockers given that she had an allergy to. Therefore, we upheld this aspect of the complaint. The board said that they have taken action to address these failings and we have asked them to provide evidence of this.

Ms C also complained that the board had failed to provide an accurate account of Ms A's death. We found that the board's response on this matter had been accurate. We did not uphold this aspect of the complaint.

Ms C complained that the board failed to communicate appropriately with her family. We found that it had been unreasonable for the board not to contact the next of kin when Ms A deteriorated. We upheld this aspect of the complaint. However, we noted that the board had acknowledged and apologised for this failure and we made no further recommendations in relation to this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to provide reasonable care and treatment to Ms A in the hospital's emergency department. 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 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.