Health

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.

Summary

Mr C complained on behalf of his partner (Ms A) who had been diagnosed with lung cancer. She also suffered from other illnesses.

Ms A had experienced shortness of breath and fatigue. It was established that she had anaemia and was referred to St John's Hospital for a blood transfusion by the oncology team at another hospital. When Ms A arrived at St John's Hospital there were no beds and before being transferred to the Medical Assessment Unit (MAU) she spent seven hours on a temporary bed in the corridor. She was eventually transferred to MAU and was given a blood transfusion later that night. Later, she was moved to an observation ward and the next day she was discharged home.

A few days later, Ms A was unwell again and she was admitted to St John's Hospital once more. Again, she spent a number of hours in a corridor before being admitted to the MAU. Mr C complained that these events were unacceptable given Ms A's serious illness. The board recognised that the situation had not been ideal but said that on both occasions the hospital had been extremely busy. They apologised but said that they could not give assurances that the same situation would not occur again. They confirmed that Ms A had been treated in accordance with the cancer treatment helpline advice. They added that St John's Hospital had asked the referring hospital whether the transfusion could be deferred the first time Ms A attended hospital but were told that it could not.

We took independent advice from consultants in general medicine and oncology (cancer). We found that although the board had no control over the number of patients arriving at the same time, it was, nevertheless, unreasonable that a cancer patient like Ms A should have had to wait so long (seven hours each time) before being transferred to MAU. We also found that there was no clinical reason why Ms A should have been given a blood transfusion late at night. For these reasons we upheld the complaint. Although Mr C had also complained about the cancer treatment helpline, this was a national helpline run by another public body and the board could not be held responsible for the policy of another organisation.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A for the time required to wait before transferred to MAU. The apology should meet the standards set out in the SPSO guidelines on apologyavailable at www.spso.org.uk/information-leaflets.
• Apologise to Ms A for giving a blood transfusion late at night when there was no urgent requirement to do so. The apologies should meet the standards set out in the SPSO guidelines on apologyavailable at www.spso.org.uk/information-leaflets.

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

• Cancer patients in particular should be admitted to MAU in a timely manner.
• Blood transfusions should be given in line with National Institute for Health and Care in Excellence guidelines.

Summary

Mr C complained that the board had failed to provide a reasonable standard of psychiatric (the branch of medicine that deals with mental illness) care and treatment to his wife (Mrs A) before her death. Mrs A had been diagnosed with a brain tumour. The psychiatrist responsible for her care considered that she had a depressive illness, but Mrs A's family disagreed with this. Mr C also complained about the comments the psychiatrist made at a consultation.

We took independent advice from a consultant psychiatrist. We found that the psychiatric care and treatment provided to Mrs A had been reasonable. However, we considered that some of the language the psychiatrist used was unhelpful and left the family feeling criticised. We considered this had been unreasonable and upheld this aspect of Mr C's complaint.

Mr C also complained that the board failed to handle his complaint reasonably. We found that although Mr C had clearly expressed dissatisfaction in an email, the board had failed to record this as a complaint or to contact Mr C for clarification. When Mr C subsequently made a further complaint, the board then delayed in responding to this. Therefore, we also upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and his family for the shortcomings in the psychiatrist's approach to the assessment. 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:

• Medical staff should communicate with patients and their families appropriately. They should use appropriate language and ensure that families have adequate support where difficult discussions are necessary.

In relation to complaints handling, we recommended:

• Complaints should be dealt with promptly and in line with the board's complaints handling procedure.

Summary

Mrs C complained about the care and treatment her daughter (Miss A) received when she presented to the board with unexplained weight loss and upper abdomen pain. In particular, Mrs C complained about the investigations carried out to try and diagnose Miss A and the delay in diagnosing her with stomach cancer.

We took independent advice from a consultant general surgeon. We found that the majority of the investigations and tests carried out to try and diagnose Miss A were reasonable. However, we also found that:

a request for an endoscopic ultrasound (procedure that allows a doctor to obtain images and information about the digestive tract and the surrounding tissue and organs) should have been marked as urgent;

that the board did not enquire about the status of the endoscopic ultrasound request with the other hospital when it had not been scheduled within a certain period of time;

a lesion on Miss A's skin was not excised urgently; and

that the board should have considered requesting another urgent endoscopic ultrasound or a repeat scan when Miss A's symptoms were ongoing.

We also found that the interim discharge summaries did not contain sufficient information about the treatment provided, investigations carried out or any

follow-up treatment/recommendations and that the formal discharge letters were not sent within a reasonable period of time.

In light of the above, we upheld Mrs C's complaints, though we found that Miss A's prognosis would have remained poor even if an earlier diagnosis had been made.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to mark the requested endoscopic ultrasound as urgent; enquire about the status of the endoscopic ultrasound request; urgently excise the lesion on Miss A's skin; consider requesting an urgent endoscopic ultrasound or a repeat CT scan; ensure interim discharge summaries contained sufficient information; and send formal discharge letters within a reasonable amount of time. 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:

• Patients in a similar situation, who present with an abnormal mass in the upper stomach and persistent symptoms of pain, anaemia and weight loss, should have endoscopic ultrasounds requested on an urgent basis.
• Where an endoscopic ultrasound has been requested but not carried out within a reasonable time frame, this should be followed up.
• Where the board considers that a lesion should be urgently removed, the procedure should be carried out urgently.
• A request for an urgent endoscopic ultrasound or a repeat CT scan should be considered for patients in a similar situation with suspected stomach cancer who have normal gastric emptying studies and ongoing symptoms four months after presenting to the board.
• Interim discharge summaries should contain sufficient information to plan a transfer of care, including the treatment provided, investigations carried out and any follow-up treatment/recommendations.

Summary

Ms C complained about the care and treatment her mother (Ms A) received from the board following a referral for the suspicion of cancer.

We took independent advice from a consultant respiratory physician and a consultant radiologist (a specialist in the analysis of the body). We found that the scan guided biopsies (tissue samples) were not carried out by the radiology department within a reasonable length of time and that there was an unreasonable delay in arranging surgical treatment. We also found that it was unreasonable that the report of a scan did not mention the bony lesions (areas of bone that are changed or damaged) and the pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs). Therefore, we upheld Ms C's complaints.

Ms C also complained that the board failed to handle her complaint reasonably. We found that the board's complaint response commented on Ms A's financial difficulty when this was not raised in Ms C's complaint. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to carry out the CT guided biopsies within a reasonable length of time; report the bony lesions and the pulmonary embolus in the report of the CT pulmonary angiogram scan; and to ensure that the complaint response only contained information that was relevant to the complaint Ms C raised. 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 radiology department should carry out CT guided biopsies within a reasonable length of time.

In relation to complaints handling, we recommended:

• Complaint responses should only contain information that is relevant to the complaint raised.

Summary

Ms C had an ad-hoc consultation with a podiatrist (a clinician who diagnoses and treats abnormalities of the lower limb). The podiatrist asked a diabetic consultant if they would review Ms C on the same day. Ms C was concerned that the diabetic consultant did not see her.

Summary

Mr C complained that the practice wrongly focused their assessment and treatment on the wrong condition, which caused a delay in him being diagnosed with pancreatic cancer.

We took independent GP advice and found that the care provided, and investigations carried out, were in line with the Scottish Cancer Referral Guidelines. When Mr C's symptoms changed, the appropriate referrals were made. We did not uphold the complaint.

Summary

Mr C complained about the treatment he received from the board, when he was referred for the provision of a specialist prosthetic (artificial substitute or replacement of a part of the body). Mr C had to travel a long distance and attend a number of consultations because he had problems with the prosthetic which had been provided and it failed to fit his limb properly, and was out of alignment.

We took independent advice from an adviser. We found that the staff had listened to Mr C's concerns and made a number of attempts to provide him with a satisfactory fit for the prosthetic but they were unable to meet his needs. We did not uphold the complaint.