Health

Summary

Mrs C complained that the practice failed to provide her late aunt (Ms A) with appropriate care and treatment. Ms A visited the practice on three occasions and was later admitted to hospital where she was diagnosed with septicaemia (blood poisoning), multi-organ failure and metastatic gastric (stomach) cancer. Mrs C complained that the practice failed to reasonably investigate Ms A's symptoms. Mrs C also complained that the practice failed to respond to her complaint in a reasonable way.

The practice acknowledged that there were shortcomings in record-keeping and checking observations. The practice apologised and took action to address these issues.

We took independent advice from an adviser in general practice medicine. We found that the investigation and treatment decisions provided to Ms A at each of the three consultations were of a reasonable standard and that an emergency admission to hospital by ambulance was not required given the circumstances. We considered that the standard of medical care and treatment provided to Ms A was reasonable. We also found that the practice responded to Mrs C's complaint in a reasonable way. Therefore, we did not uphold Mrs C's complaints.

Summary

Ms C complained about the care and treatment provided to her late husband (Mr  A) by the board in relation to treatment of his cancer. Ms C raised concerns that after a scan which showed progression of Mr A's cancer, neither the radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) nor oncologist (a doctor who specialises in the treatment and management of cancer) involved in his care contacted him to discuss this with him. Ms C said that Mr A did not discover that his cancer had progressed until he contacted his GP several month later. Ms C also complained that when Mr A was having palliative chemotherapy (a treatment for terminal cancer to prolong survival and minimise suffering, but which cannot cure the disease) the oncologist failed to identify or investigate his low haemoglobin (a protein in the blood that carries oxygen).

We took independent advice from a consultant oncologist. We found that it was reasonable that Mr A's low haemoglobin was not identified as he had not been reporting unusual symptoms. However, we found that the failure to contact Mr A to discuss his scan results was unreasonable. We determined that this was due to a miscommunication between the oncologist and radiologist and that the radiologist had changed their practices as a result of this complaint. However, we upheld Ms C's complaint and made a further recommendation to the board regarding this failing.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the breakdown in communication which resulted in neither the oncologist nor radiologist contacting Mr A to discuss the scan results. 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:

• When two or more specialists are involved in a patient's care, it should be clear who is going to contact them to discuss their ongoing treatment, and this contact should be made in a timely manner.

Summary

Ms C, a support and advocacy worker, complained on behalf of her client (Ms A) about the care and treatment Ms A received at Queen Elizabeth University Hospital following an operation. Ms A also considered that she had not received a transparent account of events of her post-operative care.

We took independent advice from a nurse. We found that Ms A had issues with urine retention after surgery. Ms A reported not feeling well and this was responded to by nursing staff; however, no attempt was made to catheterise (a  process that involves inserting a tube to the patient's urethra to allow urine to drain freely from the bladder for collection) Ms A, prompt her to self-catheterise or to take a bladder scan. We also noted there were inadequate records of Ms A's fluid balance.

Ms A also had issues with the surgical stockings she was required to wear after her operation, as she found these to be too tight. We noted that according to the Scottish Intercollegiate Guidelines Network (SIGN) guideline 122 a lack of mobility after surgery put a patient at risk of venous thromboembolism (a blood clot that starts in a vein) and devices such as surgical stockings should be worn unless there are specific reasons why these should not be used. We noted that there was no record of an assessment being carried out and we considered this should have been documented. However, as there was no evidence in the notes to raise concerns about the fit of the stockings, it was reasonable that these were worn.

In relation to the board's response to Ms A's complaint, we found that the board did not provide a full, objective and proportionate response.

We upheld both of Ms C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A for failing to perform a bladder scan and/or prompt Ms A to self-catheterise, failing to keep adequate records and for failing to provide Ms A with a full and objective response to her complaint. The apology should meet the standards set out in theSPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Nurses should have clear guidelines to ensure a consistent approach to the indicators patients should achieve during an assessment period or a trial of voiding post catheter removal.
• Assessment of the suitability of surgical socks recorded prior to application and regular review of these should be documented as part of ongoing care planning.

In relation to complaints handling, we recommended:

• The board should follow their complaints handling procedure and issue appropriate responses.

Summary

Mr C attended the Western Infirmary Hospital a number of years ago when he was experiencing dizziness and migraines. Mr C was referred for an MRI scan to investigate his condition further. Several years later, Mr C was diagnosed with a schwannoma (a tumour on the nerve tissue). His original MRI scan images were reviewed and he was told that the tumour had been visible at that time.

Mr C complained that there was a failure to investigate the tumour when he first attended hospital as it had been visible in his MRI scan. We took independent advice from a consultant neuroradiologist (a radiologist who specialises in the use of radioactive substances, x-rays and scanning devices for the diagnosis and treatment of diseases of the nervous system). We found that in retrospect, the tumour was visible in the original MRI scan. However, as it was small and not clearly defined, we found it was reasonable that it was not identified at that time. We found that even if the tumour had been identified then, it was reasonable for it not to have been reported as it was only borderline abnormal. We also found that Mr C did not yet have any sign of a neck tumour or any symptoms relating to it. We did not uphold this aspect of the complaint.

Mr C also complained that the board failed to provide an appropriate response to his complaint. We found that their response did not accurately identify all of his concerns or provide a reasonable response to them. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not accurately identifying and providing an appropriate response to all aspects of his complaint. 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:

• Complaints responses should accurately identify and provide a reasonable response to all the issues of concern.

Summary

Ms C complained about the care and treatment provided to her late mother (Mrs  A) at Vale of Leven hospital. Mrs A had been admitted with a fractured hip after a fall and remained in hospital for four months before her death. Ms C complained about a number of medical issues, including the timing of the diagnosis of the hip fracture, hydration and nutrition, diagnosis of dementia and end of life care.

We took independent advice from a consultant physician. We found that whilst the documentation of the initial assessment of Mrs A should have been more detailed, her care and treatment was reasonable. We found that Mrs A's hydration and nutrition was managed appropriately and in line with national guidelines, that the diagnosis of dementia was appropriately handled and that her care was holistic and reasonable given her declining health. We did not uphold Ms C's complaint; however, we made a recommendation to the board regarding the documentation of the initial assessment.

Recommendations

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

• Patients with an unwitnessed fall should have a full neurological (nervous system) and musculoskeletal (muscles and bones) system examination documented on admission.

Summary

Ms C complained about the care and treatment provided to her mother (Mrs A) when she attended Queen Elizabeth University Hospital for a graft repair of a brain aneurysm (a procedure in which a catheter is passed through a small cut in the groin area to an artery and then to the blood vessel in the brain where the aneurysm (a bulge in the blood vessel wall) is located in order to repair it using coils (spirals of wire) which stabilise the aneurysm). Ms C complained that there had been complications and that there was a delay in the vascular team (specialists in the treatment of diseases affecting the vascular system including diseases of the arteries, veins and lymphatic vessels) coming to assist with the repair. Ms C also said that during Mrs A's recovery, the vascular team had not reviewed Mrs A.

We took advice from a consultant in interventional neuroradiology (a specialist in minimally invasive image-based technologies and procedures used in diagnosis and treatment of diseases of the head, neck, and spine) and a vascular surgeon. We found that the graft repair of brain aneurysm procedure was carried out reasonably, and the leakage of blood where the blood vessel had been closed is a well recognised complication of this procedure. We found that the complication had been managed in a timely and appropriate way, and that the care provided to Mrs A after her surgery was reasonable. However, we found that consent for the graft repair of brain aneurysm had only been taken on the day of surgery. We considered that this should have occurred earlier in order to allow Mrs A to fully understand the procedure and risks. We also found that there was no evidence that Mrs A had been provided with an information leaflet prior to the surgery. Finally, we found that the management plan after the procedure was not adequately communicated to the relevant team. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A that the consent process was not initiated at an earlier point than on the day of the procedure, that she was not provided with an information leaflet prior to the procedure, and that the management plan after the procedure was not adequately communicated to the relevant team. 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 consent process for graft repair of a brain aneurysm should be initiated at an earlier point than on the day of the procedure (unless there is an emergency situation) and information leaflets should be provided at the appropriate time.
• The plan regarding which team are responsible for the patient should be clear.

Summary

Mrs C complained about the medical care and treatment her late mother (Mrs A) received when she attended the emergency department at Queen Elizabeth University Hospital. Mrs C said that no blood or blood gases tests were carried out before Mrs A was discharged.

We took independent advice from a consultant in emergency medicine. We found that there had been no indication to carry out blood or blood gases tests when Mrs A had attended the emergency department and that the care and treatment she received had been reasonable. Therefore, we did not uphold the complaint.

Summary

Mr C complained about the board's treatment of his Basal Cell Carcinoma (BCC, a type of skin cancer). Having undergone three initial operations to remove a BCC, he required a further operation to remove a recurrence around nine years later. Mr C complained that the board failed to treat him properly when they initially carried out the surgery.

We took independent advice from a consultant dermatologist (a doctor who specialises in the diagnosis and treatment of skin disorders).

We found that the pathology report of the third procedure should have raised concerns that the tumour may recur. We noted that Mr C had been offered a follow-up appointment, but did not seem to have been warned of the possibility of recurrence. We considered that reasonable treatment options following the pathology from the third procedure would have included consideration for Moh's surgery (surgery where thin layers of cancer-containing skin are progressively removed and examined until only cancer-free tissue remains) and/or follow-up in one to two years with the warning that the tumour could return.

The board confirmed that following the third procedure, Mr C was reviewed then discharged to his GP two months later. We found that there was no record on file that he was advised the tumour may return. There was also no record of the board having considered treatment with Moh's microsurgery, although they confirmed that it was available at the time in question. Therefore, we upheld Mr  C's complaint.

Although we upheld the complaint, we noted the board's comments that had they provided a longer follow-up over two years, this would not have detected or prevented the later occurrence of the BCC. We accepted that it was unlikely this would have detected the recurrence. We also noted that there was no evidence that the surgeries were carried out incorrectly or that they contributed to the recurrence.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to consider possible Moh's microsurgery treatment, to arrange an appropriate timeframe for follow-up and to advise of the risk of recurrence of the tumour. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

Summary

Mrs C complained about the care and treatment that her child (Child A) received from the orthopaedic department (the branch of medicine that deals with diseases and injuries of the musculoskeletal system) and the rheumatology department (the branch of medicine that deals with rheumatism, arthritis, and other disorders of the joints, muscles, and ligaments) at the Royal Hospital for Sick Children, Yorkhill.

We took independent advice from a consultant spinal surgeon and a rheumatologist. We found that:

Mrs C was not informed that the possibility of a spinal x-ray had been discussed following Child A's appointment with the orthopaedic department.

there was no record of the referral that the orthopaedic department made to physiotherapy.

there was no record of the discussions within the orthopaedic department about the risk of doing an x-ray on Child A's spine.

there was no record of the referral that physiotherapy made to rheumatology.

the plan to watch Child A's back for changes did not happen.

We upheld Mrs C's complaints about the care and treatment provided following Child A's referral to the orthopaedic department and the rheumatology department.

Mrs C also complained about the way the board handled her complaint. We found that the board failed to acknowledge Mrs C's complaints in writing within three working days and failed to keep Mrs C updated about the reason for the delay in responding to her complaints and provide a revised timescale for a response. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and Child A for failing to provide Child A with reasonable care and treatment following their referral to the orthopaedic department and the rheumatology department, for failing to communicate reasonably with Mrs C and for failing to handle Mrs C's complaint reasonably. 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 and/or their parent/guardian should be informed when an x-ray is being considered following the identification of scoliosis (abnormal lateral curvature of the spine).
• Clear records of inter-disciplinary referrals and discussions should be kept.
• Clear records should be kept of discussions about the risk of performing an x-ray on a child's spine.
• Clear records of inter-disciplinary referrals and discussions should be kept.

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

Summary

Having been diagnosed with lung cancer, Mrs C complained that she had been attending the practice for years with breathlessness and she considered that she should have been referred for specialist investigation sooner. The practice noted that Mrs C was fully investigated for intermittent complaints of breathlessness, and that she was diagnosed with chronic obstructive pulmonary disease (COPD - a disease of the lungs in which the airways become narrowed). The practice said that when Mrs C presented with new symptoms (a nocturnal cough along with worsening breathlessness) she was promptly investigated and the diagnosis of lung cancer was made. They did not consider there were previously any suggestive symptoms that might have prompted an earlier referral for suspicion of cancer. They noted that the grading of the cancer indicated it had been detected relatively early, and they considered that her COPD was the more likely source of her breathlessness.

We took independent advice from a GP. We found that it was reasonable for the practice to have made a presumptive diagnosis of COPD and that they sought to manage this within the primary care setting. The adviser said that the practice could have considered requesting a chest x-ray and respiratory referral around ten months earlier than they did, as Mrs C had reported worsening breathlessness (not just on exertion but also at rest). However, the adviser did not consider it unreasonable for them not to have taken that approach. They noted Mrs C was referred for breathing tests at that time, which confirmed the COPD diagnosis. On balance, we did not uphold the complaint.