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Health

  • Report no:
    201708494
  • Date:
    March 2019
  • Body:
    Grampian NHS Board
  • Sector:
    Health

Summary

Mrs C complained about the care and treatment that her late husband (Mr A) received from Grampian NHS Board (the Board).  Following his GP referral to the Board, Mr A was diagnosed with kidney cancer.  He had surgery to remove part of his kidney, which appeared to have removed all of the cancer.  However, around two years later, it was found that Mr A's kidney cancer had returned.  He was referred for further surgery to remove the rest of his kidney, which was then cancelled.  When Mr  A attended oncology (cancer specialists) to discuss other treatment options, he was told his cancer was terminal and it had spread more widely than previously identified.  Sadly, Mr A died early the next year.

Mrs C complained about a delay in first diagnosing and treating Mr A's kidney cancer.  She also complained about a delay in diagnosing and treating Mr A's kidney cancer when it returned and spread to other areas of his body.  Mrs C raised particular concerns that there was a delay in advising them of the seriousness of Mr A's condition. 

We took independent advice from a consultant urologist and a consultant radiologist, which we accepted.  We found that there was an unreasonable delay in diagnosing Mr A's kidney cancer, as his first GP referral was not actioned by the Board.  We found there was also an unreasonable delay in diagnosing that Mr A's kidney cancer had returned and spread.  This was due, in part, to a series of failings in interpreting the results of Mr A's scans.  We also found significant failings in the communication with Mr A about his condition and its seriousness.

Mrs C was also unhappy with how the Board dealt with her complaint.  We found that there was an unreasonable delay in dealing with Mrs C's complaint.  We also found the Board failed to thoroughly investigate or address all of Mrs C's concerns.  We were very concerned that the Board's review failed to identify or acknowledge the significant failings in their communication with Mr A and his family.

We upheld Mrs C's complaints.  We made a number of recommendations to address the issues identified.  The Board have accepted the recommendations and will act on them accordingly.  We will follow up on these recommendations.  The Board are asked to inform us of the steps that have been taken to implement these recommendations by the date specified.  We will expect evidence (including supporting documentation) that appropriate action has been taken before we can confirm that the recommendations have been implemented.

 

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Mrs C:

Complaint number

What we found

What the organisation should do

Evidence SPSO needs to check that this has happened and the deadline
(a) and (b)
  • The Board unreasonably delayed in diagnosing Mr A's kidney cancer;
  • The Board unreasonably delayed in diagnosing Mr A's kidney cancer had returned and spread;
  • The communication with Mr A about his condition was unreasonable; and
  • The Board's complaints handling was unreasonable

Apologise to Mrs C for the unreasonable delays in Mr A's care and treatment; the failure to communicate reasonably with Mr A about his condition and the failings in the Board's complaints handling

A copy or record of the apology.  The apology should meet the standards set out in the SPSO guidelines on apology available at:

www.spso.org.uk/leaflets-and-guidance

 

By:  22 April 2019

We are asking the Board to improve the way they do things:

Complaint number

What we found

What should change

Evidence SPSO needs to check that this has happened and deadline
(a)

The Board's cancer treatment times, for both the partial nephrectomy and radical nephrectomy, exceeded the national targets

In similar cases, patients should receive treatment within 62 days of the referral and within 31 days from the decision to treat, as per the national targets

 

 
  • Evidence that the findings of this investigation have been fed back to the relevant clinicians in a supportive way that promotes learning
  • Evidence of the steps being taken to reduce waiting times for treatment and better meet the national targets
     

By:  20 May 2019
(a) There were multiple instances where clinically significant abnormalities were missed when CT scans were reported and reviewed Radiological findings should be accurately reported as far as possible
  • Evidence that the findings of this investigation have been fed back to the relevant radiologists in a supportive way that promotes learning
  • Confirmation that the individual radiologist(s) will discuss this case at their next appraisal
     

By:  20 May 2019
(a) The multidisciplinary team (MDT) did not review and/or identify the errors in the reporting of Mr A's CT scans

There should be systems and safeguards in place to ensure:

  • the MDT actively review CT scan imaging, including, where appropriate, a re-assessment by a radiologist and a comparison with older imaging 

And

  • the radiologist is resourced, with the time, technology and support, to do this before the MDT for all cases and to issue addenda afterwards if required

Evidence of the systems in place to ensure that CT scan imaging is reviewed appropriately before MDTs and how this will provide necessary safeguards
 

By:  20 May 2019
(a) The MDT referred Mr A for a radical nephrectomy when it was not technically feasible Systems should be in place to ensure the surgeon (for patients due to undergo complex or major surgery), inputs to the MDT on whether the surgery being considered or recommended by the MDT is technically feasible

Evidence that the Board has reviewed and where appropriate amended its approach, to ensure the views of operating surgeons on technical feasibility are considered.
 

By:  20 May 2019
(a) There was a delay in carrying out the imaging requested by the MDT to investigate the extent of Mr A's cancer Systems should be in place to ensure requests for imaging by the MDT are  followed up with an urgent imaging request and an automatic MDT review as soon as the imaging has been completed

Evidence that the Board has reviewed the MDT approach and supporting processes to ensure that any imaging requested by the MDT is carried out within an appropriate timescale
 

By:  20 May 2019
(a) The consultant urological surgeon's communication with Mr A about his condition was unreasonable Patients should be given prompt, clear, realistic and honest information about their condition, its seriousness and the likely chance of success from any treatment options
  • Evidence that the findings of this investigation have been fed back to the individual consultant urological surgeon in a supportive way that promotes learning.
  • Confirmation that the individual consultant urological surgeon will discuss this case at their next appraisal.
  • An explanation about how this will inform wider learning in the Board

By:  20 May 2019
(a) There were errors in CT scan reports by the private company used by the Board for radiology outsourcing Radiological findings should be accurately reported

Confirmation that the Board has a system in place to feedback reporting discrepancies to any private radiology companies they use for outsourcing work
 

By:  20 May 2019

 

We are asking The Board to improve their complaints handling:

Complaint number What we found Outcome needed What we need to see
(b) There was an unreasonable delay in the Board's complaints investigation, partly because they tried to arrange a meeting with Mrs C before issuing a formal response to her concerns

Complaints should be handled in line with the model complaints handling procedure.

The model complaints handling procedure and guidance can be found here: www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs

Evidence that the outcome of this investigation has been fed back to staff in a supportive manner which encourages learning, and that all staff are aware of and understand the complaints handling procedure
 

By:  20 May 2019

 

 

 
(b) The Board’s own complaints investigation did not identify or address all of the failings in the care provided to Mr A The Board's complaints handling system should ensure that failings (and good practice) are identified, and enable learning from complaints to inform service development and improvement

Evidence that the Board have reviewed why its own investigation into the complaint did not identify or acknowledge all the failings highlighted here
 

By:  20 May 2019

Evidence of action already taken

The Board told us they had already taken action to fix the problem.  We will ask them for evidence that this has happened:

Complaint number What we found Outcome needed What we need to see
(a) The Board told us they have improved the pathway for GP referrals

The Board should have a clear reliable pathway for both electronic and paper referrals

 

Details of the current referral pathway for electronic and paper GP referrals and how they are actioned
 

By:  22 April 2019

 

 

 
(b) The Board told us that they discussed the errors in the CT scan reporting at a radiology discrepancy meeting As far as possible, radiological findings should be accurately reported
  • Evidence that this case has been discussed at the departmental radiological 'learning from discrepancies' meeting.
  • Confirmation that in discussing these errors, the CT scan imaging was examined and compared with earlier CT scans
     

By:  22 April 2019

Feedback

Points to note:

Adviser 2 explained that it would have been best practice for the reporting radiologist to make a direct referral to the MDT in 2014.  However, they might not have been aware of the local process to do so because they were working remotely for a private company.  The Board might wish to make private companies aware of the local process for radiologists to make direct MDT referrals.

Adviser 1 noted that Mr A waited four weeks to be told about his kidney cancer, after his diagnosis was confirmed by the January 2014 CT scan and his treatment was discussed by the MDT.  The Board might wish to consider if it is possible to streamline this process so patients are offered earlier urology appointments in similar circumstances.

Adviser 1 considered that the Board could have written to Mr A about the histology findings at the same time as they wrote to his GP.  The Board might wish to consider copying patients into these types of GP letters in future.

Adviser 2 commented that the use of standardised CT protocols would make it easier to compare any follow-up CT scans with previous CT scans.  The Board might wish to carry out a review of CT protocols to ensure that optimum diagnostic quality imaging is obtained across the whole range of clinical scenarios or possible pathologies.

Related reading

  • Case ref:
    201805151
  • Date:
    March 2019
  • Body:
    NHS 24
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    complaints handling

Summary

Mr C complained about the advice he received from NHS 24 staff when he called for assistance for a dental problem. He spoke to a dental nurse initially who advised that he should take painkillers and contact his dentist when the practice opened later that morning and ask for an urgent appointment. Mr C was unhappy with this advice and asked to speak to another dental nurse and again remained dissatisfied with the advice given. The telephone calls to NHS 24 became challenging and staff terminated a call as Mr C was deemed to have been offensive.

We took independent advice from a dentist. We found that the advice that Mr C should attend his own dentist later that morning was appropriate. It was also appropriate that he was given advice to take painkillers and that there was no medical need for an emergency appointment. We also found that Mr C's behaviour during the calls was challenging for all concerned and that it was not unreasonable for the staff to have terminated the call when it was clear that nothing further would be achieved. We did not uphold the complaint.

Related reading

  • Case ref:
    201804326
  • Date:
    March 2019
  • Body:
    Scottish Ambulance Service
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mrs C complained about the treatment she received from the ambulance service. Mrs C said that she told the paramedic she had chest pains and had vomited a lot of blood. She said the paramedic refused to carry out a proper assessment and returned to their vehicle. Mrs C dialled 999 again and the paramedic returned to the house. The paramedic spoke to Mrs C's GP and it was arranged that she should make an appointment at the practice to discuss her health problems. Mrs  C made a further call to the ambulance service 12 hours later and was then taken to hospital.

We took independent advice from a consultant in emergency medicine. We found that there was a difference in recall between the paramedic and Mrs C about the amount of blood she had lost whilst vomiting. The paramedic had recorded that Mrs C had only coughed up a small streak of blood. If the paramedic's recall was the more accurate, then there was no requirement to take her to hospital. However, had she vomited a lot of blood as had described in the later call for assistance then a transfer to hospital was appropriate. While there was some contact between the paramedic and Mrs C's GP, the GP's phone note did not mention any blood loss.

On balance, we decided that in view of the record of little blood loss and the facts that the paramedic had made contact with the GP practice, Mrs C did not seek additional medical assistance for a period of 12 hours; and that her symptoms at that time were vastly different from before, that the actions of the paramedic were reasonable. We did not uphold the complaint.

Related reading

  • Case ref:
    201803603
  • Date:
    March 2019
  • Body:
    NHS 24
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Ms C complained that NHS 24 failed to provide her with an appropriate assessment of her condition and advice during a telephone call.

We took independent advice from a GP. We found that the questions asked by NHS 24 to assess Ms C's condition were reasonable and that there was no clinical indication for Ms C to be advised to attend A&E. We also noted that Ms  C was advised to see a pharmacist. We found that, ideally, Ms C should have been referred directly to the out-of-hours service, but it was not unreasonable or unsafe for Ms C to be advised to see a pharmacist. We did not uphold Ms C's complaint.

Related reading

  • Case ref:
    201707406
  • Date:
    March 2019
  • Body:
    Tayside NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mr C complained about the treatment he received from the board for pain in his thigh. Mr C said that he attended Perth Royal Infirmary and Ninewells Hospital over nearly a three year period for treatment for his condition and was seen by three different consultant vascular surgeons (a specialist in the treatment of diseases affecting the vascular system including diseases of the arteries, veins and lymphatic vessels). Mr C said he was not satisfied with the treatment suggested by the consultants and was subsequently seen and assessed by a surgeon at a private hospital, who carried out treatment which cured the pain in Mr C's thigh.

We took independent medical advice from a consultant vascular surgeon. We found that Mr C's treatment by the board was reasonable and found no failings in the treatment offered. Therefore, we did not uphold this part of Mr C's complaint.

Mr C also complained that the board failed to provide him with an adequate response to his complaint. We found that aspects of the board's response to Mr C's complaint did not appear to match with the evidence in the medical record and the response also failed to answer all Mr C's questions at the end of his letter of complaint. Therefore, we upheld this part of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Mr C for the failure in complaint handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance

In relation to complaints handling, we recommended:

  • Responses to complaints should take into account the evidence in the medical records and address all the issues raised, in accordance with the NHS Scotland Complaints Handling Procedure.

Related reading

  • Case ref:
    201706659
  • Date:
    March 2019
  • Body:
    Tayside NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    communication / staff attitude / dignity / confidentiality

Summary

Mrs C complained that certain risks associated with knee replacement surgery she underwent at Ninewells Hospital had not been explained to her when she consented to the operation. She also complained that the wrong size of implant was used and that cement had leaked and caused nerve injury. Mrs C underwent additional surgery a couple of days later to remove the cement.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the recognised risk of some complications were not documented as having been explained to Mrs C in line with the General Medical Council's consent guidance. We considered this was unreasonable and upheld this aspect of Mrs C's complaint.

Whilst we could not say for certain what caused Mrs C's nerve damage (a recognised risk of surgery that was explained to her during the consent process), we considered it was unlikely to be related to the cement leakage. However, we were concerned about actions of staff in relation to the sizing of the implants and the lack of experienced staff present in the theatre at the time of implantation. Therefore, we upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Mrs C for failing to inform her of all the recognised risks of the surgery, for the inappropriate circumstances around component sizing, lack of experienced staff in theatre and record-keeping failures. 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 should receive full information on the risks of surgery in accordance with recognised guidance such as the General Medical Council.
  • Implant sizing is the operating surgeon's responsibility; and all relevant staff should ensure they are present in the theatre.
  • Staff should ensure thorough and contemporaneous record-keeping of all relevant events during surgery.

Related reading

  • Case ref:
    201803163
  • Date:
    March 2019
  • Body:
    Lothian NHS Board - Acute Division
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mrs C complained that the board unreasonably delayed in diagnosing secondary breast cancer. Following treatment for breast cancer, Mrs C underwent annual check-ups with a consultant surgeon where she complained of a lump and pain near her reconstructed breast (a breast that has been reshaped following a mastectomy (breast removal)). Mrs C said that these reports were not appropriately investigated.

We took independent advice from a specialist in breast cancer. We found that investigations were carried out when Mrs C first reported a lump near the reconstruction and that relevant guidelines did not recommend routine mammography (x-ray of the breast) of the reconstructed site and associated axilla (underarm). We considered that the board had practised within the national recommendations and Mrs C was followed up and examined regularly. We also found that when Mrs C presented with a new lump it was investigated and treated in a timely manner. We found that the standard of medical care was reasonable and there had not been an unreasonable delay in diagnosing the recurring cancer. We did not uphold the complaint.

Related reading

  • Case ref:
    201800737
  • Date:
    March 2019
  • Body:
    Lothian NHS Board - Acute Division
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    complaints handling

Summary

Ms C complained that the board's response to her complaint was unreasonable and contained many errors.

We found that the board's response was an accurate reflection of their records of Ms C's treatment. The board explained why they could not delete entries from Ms C's medical records, and added Ms C's handwritten note to the records to reflect her view of events.

The board acknowledged that they could have provided Ms C with better information and support to make informed choices about ongoing treatment, and said they were sorry for this. Ms C chose to get private treatment as she was unhappy with the treatment she had received from the board and wanted the board to pay for this. The board offered Ms C different treatment options and consultations with different doctors but Ms C declined this offer. The board's response explained why, under the circumstances, they could not pay for Ms C's private treatment.

We considered that the board's response to Ms C was reasonable. Therefore, we did not uphold the complaint.

Related reading

  • Case ref:
    201800428
  • Date:
    March 2019
  • Body:
    Lothian NHS Board - Acute Division
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mr C complained that his wife (Mrs A) had undergone open heart surgery at Edinburgh Royal Infirmary when she had been due to undergo a less invasive procedure. Following surgery, Mrs A was transferred to another hospital where she died shortly afterwards. Mr C said that his wife suffered from dementia and could not have understood the decision to change the procedure or have provided informed consent. Mr C noted he had welfare power of attorney and accompanied his wife to all her appointments. Mr C said that he had not been informed about the change of procedure. Mr C also complained that Mrs A was unreasonably discharged to another hospital. Mr C felt that Mrs A would have survived if she had been treated differently.

We took independent medical advice from a consultant cardiothoracic surgeon (a specialist who operates on the heart, lungs and other chest organs). We found that Mrs A's procedure was changed after an appropriate assessment of the risks of both types of surgical procedure and that it was reasonable to proceed with open heart surgery. There was no evidence that Mrs A's chances of survival were compromised by this decision. We also found that an assessment had been carried out which found that Mrs A had a mild memory impairment, however, medical staff were satisfied that she had the capacity to understand and consent to the change in procedure. We considered that this was reasonable. Therefore, we did not uphold these aspects of Mr C's complaint.

In relation to the hospital transfer, we found that this was unreasonable given Mrs  A's condition. We upheld this aspect of Mr C's complaint. However, we could not determine that Mrs A would have survived if this had not taken place.

In relation to the board's communication with Mr C and his family, we found that Mrs A had been in hospital for over a week prior to the procedure due to a chest infection and that Mr C had been present every day. We considered that the board should have discussed Mrs A's care when Mr C was present. Therefore, we upheld this aspect of Mr C's complaint. We noted that the board had acknowledged and apologised for this failing.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Mr C for unreasonably deciding to transfer Mrs A to another hospital before she had sufficiently recovered from surgery. 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:

  • Review their policies and procedures for patient transfer to ensure that distance travelled is taken into account as part of the decision.

Related reading

  • Case ref:
    201701267
  • Date:
    March 2019
  • Body:
    Lothian NHS Board
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    nurses / nursing care

Summary

Mr C complained about the care provided to his wife (Ms A) during a home birth, in particular that two midwives did not attend at the same time.

We took independent advice from a midwife. We found that it was standard practice for one midwife to attend first and that the role of the second midwife is to assist in the event of an emergency requiring one-to-one care. We considered that there was no requirement for emergency care for either Ms A or their child, and therefore, no requirement for a second midwife to be present. We did not uphold this aspect of Mr C's complaint.

In the days after the birth, community midwives attended Mr C's home and following an incident, the board decided not to allow any further visits to Mr C's home if he was present. Mr C complained that this decision was unreasonable.

We found that the board's actions had been appropriate and the decision taken was reasonable based on the available information. Therefore, we did not uphold this aspect of Mr C's complaint. However, we considered that a further risk assessment should be undertaken in the event of any future pregnancies, to review the requirement for the restriction to remain in place, and we fed this back to the board.

Related reading

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