Health

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.

Summary

Mr C complained that his wife (Ms A) contracted methicillin-resistant staphylococcus aureus (MRSA - a bacterial infection that is resistant to a number of widely used antibiotics) due to medical negligence in the Princes Royal Maternity Unit (PRMU), and of a subsequent delay in identifying and appropriately treating the infection. Mr C considered that Ms A contracted MRSA as a result of negligence following the birth of their child. He considered that there was a delay in medical staff diagnosing the infection and thereafter providing proper treatment. Ms A returned home, continuing to have difficulties, and had to receive treatment despite having been discharged from the PRMU.

We requested the relevant medical files and asked an independent medical adviser to consider the care and treatment provided to Ms A. The medical records evidenced that the treatment in hospital had been appropriate, with Ms A's observations being monitored appropriately and decisions taken to discharge her were reasonable in the circumstances. However, on re-admission it was apparent Ms A was suffering from an infection. We found that appropriate investigations were undertaken in a timely manner to identify the cause of Ms A's infection when her symptoms became apparent. The antibiotic treatment was revised when tests concluded the cause of the infection was MRSA. There was no evidence of medical negligence that resulted in the infection. We concluded that the diagnosis and treatment provided to Ms A was reasonable, and therefore did not uphold the complaint.

Summary

Ms C complained about the care she received from Queen Elizabeth University Hospital's maternity assessment unit (MAU) when she called for advice with heavy bleeding at 33 weeks of her pregnancy. She also complained about the treatment she received ten days later following her admission to the hospital, at which time her baby was stillborn.

In responding to the complaint, the board apologised that they could not account for Ms C's phone contact with the MAU because there was no record of the phone call.

We took independent advice from a consultant obstetrician (a specialist in pregnancy and childbirth) and gynaecologist (specialist in the female genital tract and its disorders). We considered that the record-keeping practice was of an unacceptable standard and that the advice Ms C had received was incorrect because she should have been asked to attend hospital to have a clinical assessment of her pregnancy, in line with national guidance. We also considered that it was likely that Ms C would have been admitted to hospital for monitoring but given her bleeding stopped, it was also likely she would have been discharged. Whilst we found that it was possible that follow-up with Ms C could have been earlier than when she was seen 10 days later, we considered that the large placental abruption (separation of the placenta from the inner wall of the uterus), which she had no obvious risk factors of, could not have been prevented or predicted. We upheld the complaint.

In terms of the treatment Ms C received at the hospital when she attended by emergency ambulance with heavy bleeding 10 days later, we considered that her initial management of her abruption was inadequate and not in accordance with national guidelines. However, we also considered that these failings were unlikely to have altered the outcome for Ms C's baby. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to fully assess and treat her on arrival to the maternity unit. 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 Maternity Assessment Service should maintain adequate records of phone consultations and advice given. Staff responding to patient phone queries should be aware of guidance on the management of significant antepartum haemorrhage.
• All staff attending patients with life threatening complications such as antepartum haemorrhage should be aware of national/local guidelines on emergency management of patient collapse.
• Staff handling complaints should ensure that the issues are fully investigated with action taken to address any failings identified.

Summary

Mrs C complained about the care and treatment she received from the board for her bunions (painful swellings on the first joint of the big toes). Mrs C complained that the board failed to advise her prior to her bunion surgery that permanent nerve damage or bone fracture were potential complications of the surgery. Mrs C said that if she had been advised of these potential outcomes, she would not have gone ahead with the operation.

We took independent medical advice on the case from a consultant orthopaedic and trauma surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that nerve damage and bone fracture were recognised complications of the surgery Mrs C had. We also found that the appropriate consenting process was carried out and the correct consent form was signed by Mrs C and the doctor who was to carry out her surgery. The consent form listed the complications of the procedure, including nerve damage and fracture. Therefore, we did not uphold this complaint.

Summary

Ms C, who works for an advice and support agency, complained on behalf of Mr B about the care and treatment provided to his late wife (Mrs A) at Queen Elizabeth University Hospital. Ms C raised concerns about the medical and nursing care and treatment provided to Mrs A, about the decision to transfer Mrs A to another hospital, and that Mrs A's family were not advised of the transfer.

We took independent advice from a consultant physician/geriatrician (a medical doctor who specialises in medicine of the elderly) and a nursing adviser. We found that the medical treatment provided to Mrs A was reasonable, and did not uphold this aspect of Ms C's complaint.

In relation to nursing care, we found that whilst many aspects were reasonable, there was a failure to swab Mrs A's leg ulcers on admission to the hospital and this was a breach of the board's standard operating procedure on

meticillin-resistant Staphylococcus aureus (MRSA - a type of bacteria that is resistant to several widely used antibiotics). Mrs A's leg ulcers were found to be MRSA positive when she transferred to another hospital. We upheld this aspect of Ms C's complaint. However, we were unable to conclude if this could have been avoided if Mrs A had been swabbed on admission.

We found that the decision to transfer Mrs A to another hospital was unreasonable given Mrs A's condition and we upheld this aspect of Ms C's complaint. However we found that her family were appropriately advised of this and did not uphold the complaint about communication of the transfer.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr B for failing to swab Mrs A's leg ulcers for MRSA on admission and unreasonably transferring Mrs A to a different hospital. 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 multidisciplinary team should satisfy themselves that a patient is suitable and fit before being transferred.
• Staff should follow the board's MRSA Standard Operating Procedure.

Summary

Mr C complained about the treatment he received at his dental practice. His dentist had said that he required a filling and the filling was performed by a dental therapist. Following the filling, Mr C experienced pain from the tooth and was told that a nerve had been damaged and that he would require either extraction or root canal treatment and then that he would require a crown. Mr C felt that the dental therapist had not carried out the filling in an appropriate manner. Mr C was also dissatisfied that when he made a formal complaint to the practice that he received responses from the dental therapist, head of practice and the dentist.