Health

Summary

Ms C, an advocacy worker, submitted a complaint on behalf of her client (Ms A). Ms A was diagnosed with polycystic ovaries (a condition that affects a woman's hormone levels) after undergoing a laparoscopic (minimally invasive) surgery to untwist a torted right ovary. Further investigations were carried out, including two ultrasound scans. After experiencing severe lower abdominal pain, an emergency salping-oophorectomy (removal of the fallopian tube and ovary) was carried out. This took place two days after Ms A's second ultrasound. Ms C complained that the second ultrasound scan was not carried out appropriately and that an ultrasound scan should have taken place when she was admitted to hospital inbetween her two other scans.

We took independent advice from an obstetrics and gynaecology consultant (a  doctor who specialises in pregnancy, childbirth and the female reproductive system). We found that it was reasonable for the board to not carry out an ultrasound scan during Ms A's admission. We noted that Ms A's condition appeared to have been managed appropriately and conservatively, based on the information known at the time. We also found that an ovarian torsion can happen over a few hours and, therefore, it is possible that it had not occurred when the second ultrasound took place. We acknowledged that it was not possible to know for certain whether anything of concern was overlooked during this ultrasound, however, we considered that the board's management of Ms A's condition was reasonable and appropriate. We did not uphold either of Ms C's complaints.

Summary

Mrs C complained about a delay in diagnosing her child's (Child A) kidney condition. Mrs C was concerned that despite several years of symptoms, appropriate investigations to diagnose Child A's condition had not been carried out and that this had resulted in loss of kidney function. Mrs C also considered that the issue could have been identified on an antenatal scan. Mrs C complained to the board but was unhappy with their response to her complaint.

We took independent advice from a consultant paediatrician (a doctor who specialises in child medicine). We found that Child A's condition would now likely be identified during antenatal anomaly scanning but that at the time of Mrs C's pregnancy, there was no requirement for this type of scan to be carried out. We did not find that the diagnosis had been unreasonably missed. We noted that the board had already reflected on this case and now have a lower threshold for referring children for scans where they report pain moving towards the back. We did not uphold this aspect of Mrs C's complaint.

In relation the board's handling of Mrs C's complaint, we found that the board had not addressed her comments about the potential for diagnosing Child A's kidney condition during an antenatal scan. 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 not addressing the issues raised about prenatal diagnosis in the complaint investigation or explaining why it was not considered reasonable to do so. The apology should meet the standard set out in the SPSO guidelines on apology available at: www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Issues raised in complaints should be addressed or an explanation provided as to why it is not considered reasonable to do so.

Summary

Ms C complained about a delay in the results of a magnetic resonance imaging (MRI) scan being reported which showed that a small pancreatic tumour, which was being monitored, had grown in size. Ms C also complained that when a computerised tomography scan (CT - a scan which uses x-rays and a computer to create detailed images of the inside of the body) was carried out around four months later, there was a failure to identify a breast lump.

We took independent advice from a consultant 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) and a consultant in acute medicine. We considered that there was an unreasonable delay in the MRI scan being reported which would have impacted on the time taken to carry out further investigation of the pancreatic tumour. We upheld this aspect of Ms C's complaint and noted that the board were taking steps to address the delays in the service. We also recommended further action to be taken.

In relation to the CT scan, we found the actions of the board to be reasonable. The scan was intended to concentrate on Ms C's pancreas and liver rather than a general look for cancer anywhere. We found that it was reasonable that every organ was not examined in great detail given Ms C did not have concerning symptoms. Therefore, we did not uphold this aspect of Ms C's complaint.

Recommendations

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

• Patients receiving MRI scans should have them reported within a reasonable time frame.

Summary

Ms C injured her shoulder and attended the emergency department where she was assessed and referred to a fracture clinic. Following the appointment at the fracture clinic, it was decided the injury should be treated conservatively. At a further follow-up appointment, it was decided that Ms C should be referred for surgery. The local orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system) was unavailable and it was agreed that Ms C should wait until a specialist orthopaedic surgeon was available. Ms C complained that the board unreasonably delayed in performing the surgery.

We took independent advice form an orthopaedic surgeon. We found that it was reasonable that the injury was treated conservatively in the first instance and that they waited until a specialist surgeon was available. Ms C's outcome would have been affected not by the delay, but if the surgery was not performed by a specialist. Therefore, we did not uphold Ms C's complaint.

Summary

Ms C complained about the decision not to provide her with a gastric pacemaker (a device that electrically stimulates the muscles that empty the stomach).

We took independent advice from a gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas). We found that the decision not to provide a gastric pacemaker was reasonable as Ms C's symptoms fluctuated, she had other health conditions impacting on her condition and there was limited evidence that the gastric pacemaker would benefit her condition. Therefore, we did not uphold Ms C's complaint.

Summary

Ms C, an advocate, complained on behalf of her client (Ms A) about the care and treatment Ms A received at Glasgow Royal Infirmary. Ms A broke her distal fibia (the end of the fibula bone, one of the bones that supports the ankle joint) and underwent surgery to repair the break. Ms C said that the plate was not fixed in the appropriate place, causing poor healing and requiring further surgery to fix the error.

We took independent advice from an orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that Ms A's treatment was reasonable as the initial operation was carried out appropriately, with the plate and screws reasonably placed. Ms A was then reviewed in further clinics, with appropriate advice given to manage the healing process. There was evidence that the injury was not healing as expected and further investigations, including a CT scan were undertaken. This identified that Ms A had developed a recognised complication which led to the need for a further operation. We considered the treatment Ms A received to be reasonable and did not uphold Ms C's complaint.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Ms B) about the care and treatment provided to Ms B's daughter (Ms  A) at Glasgow Royal Infirmary. Ms A was admitted to the hospital on two occasions due to complications from her gastric band (a band placed around the stomach to give a feeling of fullness with less food). Ms A died at home, a month after she was discharged from hospital on the second occasion.

When Ms A was discharged the first time, she waited all day for an ambulance to come to transport her home. Ms C complained that nursing staff did not allow Ms  A back to bed while she waited, even though she was very uncomfortable. We took independent advice from a nurse. We found that there was no record of Ms A's nursing care needs being assessed or met while she waited for the ambulance. We upheld this aspect of the complaint.

Ms C explained that during her second admission, Ms A began to experience difficulties with her hands. Ms C complained that Ms A was not given appropriate help with eating. We found that there was a failure to assess, plan and review Ms A's nutritional care needs, with Ms A's involvement as appropriate. We upheld this aspect of the complaint.

Ms C also complained that Ms A was unreasonably discharged home without appropriate communication, particularly with her GP, about her malnutrition. We took independent advice from a consultant surgeon. We found that it was reasonable Ms A was discharged home. However, we also found that the concerns about Ms A's nutritional status and difficulties with eating should have been communicated to her GP in her discharge letter. In light of this, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms B for the failings identified in appropriately assessing, planning, reviewing and recording Ms A's nutritional care needs, and for failing to include all relevant clinical information in Ms A's discharge letter. 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 needs of patients who are waiting to be discharged from hospital should be appropriately met while they remain on the ward.
• There should be patient-centred nutritional care assessment, planning and review.
• Clinical issues of concern should be included in discharge letters so GPs are aware of the need to keep them under review.

Summary

Mr C complained to us about the care and treatment Miss A had received in the Queen Elizabeth University Hospital after she was admitted with axillary cellulitis (a bacterial skin infection around the armpit). The cellulitis increased over the next day and Miss A was eventually taken to theatre to have the damaged tissue removed.

We took independent advice from a consultant general and vascular surgeon (a  specialist in the treatment of diseases affecting the vascular system including diseases of the arteries, veins and lymphatic vessels). We found that there had been a delay in carrying out a scan when Miss A was admitted to the hospital. If an early X-ray had been carried out, the gas in the tissues would have indicated the severity of the infection and prompted immediate intervention. We considered that this delay possibly led to Miss A needing to have more tissue removed to control the infection. We upheld this aspect of Mr C's complaint. However, we were satisfied that the board had apologised for this and had taken reasonable action in response to the matter.

Mr C also complained that Miss A had been kept on blood thinning medication for too long a period. Miss A had been prescribed the medication because she had previously had clots. The medication was increased in hospital after a CT scan showed a further clot. We found that it had been reasonable to keep Miss  A on blood thinning medication while she was in hospital, as she was immobile. We did not uphold this aspect of the complaint.

Miss A's blood thinning medication was then stopped after she developed a haematoma (a mass of blood). Miss A was subsequently discharged from hospital and died at home after suffering a pulmonary thromboembolism (a  blocked blood vessel in the lungs). Mr C felt that the appropriate blood thinning medication would have prevented this and complained that it was stopped rather than reduced after Miss A developed the haematoma. We found that it had been reasonable to stop the medication in view of the haematoma. We did not uphold this aspect of the complaint.

Summary

Mr C complained on behalf of his late uncle (Mr A) about a delay in the diagnosis and treatment of bowel cancer.

In response to Mr C's complaint, the board acknowledged that there was an initial lack of diagnosis, but explained it was necessary to establish the diagnosis before embarking on a course of treatment. While the board considered that the time taken was reasonable overall, they acknowledged there had been an administrative error causing a delay in a biopsy procedure, and apologised for this.

We took independent advice from a consultant general surgeon, who explained that Mr A had a locally advanced recurrent cancer and a complicated pathway. We found that some of the investigations were performed promptly, such as the imaging and arranging of a TRUS biopsy (transrectal ultrasound guided biopsy). However, we also found that there were some delays by the board that could have been avoided, such as an administrative error causing cancellation of a procedure and issues with scheduling of treatment. We found that whilst these factors caused some delay in Mr A's management, the clinical effects of the delay would not have had any impact on his outcome. We considered that there were aspects of unreasonable delay in the diagnosis and treatment of Mr A's bowel cancer. On balance, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A's family for the instances of unreasonable delay in the diagnosis and treatment of bowel cancer. 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 on similar care pathways should receive co-ordinated and planned care.
• As far as possible, patient appointments for investigations and treatment should be processed without administrative error.

Summary

Ms C complained about the care and treatment her partner (Mr A) received during his admission to Queen Elizabeth University Hospital. After Mr A had been discharged he became unwell and was readmitted the following day. On the day of Mr A's readmission he was transferred to another hospital for specialist care where he died two days later.

Ms C raised concerns about the administration of an iron infusion which led to Mr  A receiving an overdose of iron. Ms C questioned whether this may have contributed to Mr A's death and wondered if a blood transfusion would have been a more appropriate treatment. Ms C also questioned Mr A's discharge and whether, if he had been in hospital rather than at home when he became unwell, this would have affected his outcome.

The board had acknowledged that although the total dose of iron calculated for Mr A was accurate, he received a dose of iron higher that the recommended dose for a single infusion. They said that Mr A was monitored appropriately in case of an infusion reaction and his observations were stable on his discharge. The board also acknowledged there was an error in Mr A's medication on his discharge.

We took independent advice from a consultant in acute medicine. We found that all appropriate investigations and interventions were undertaken and it was reasonable to have discharged Mr A with the follow-up plans the board had set out. We also noted that Mr A was well enough for these to be arranged on an out-patient basis.

In relation to the iron infusion, we found that it was reasonable to have given this to Mr A to treat his anaemia and that this was more appropriate than a blood transfusion. While we could not exclude it absolutely, we considered that there was no evidence to suggest that the larger dose of iron that Mr A received had contributed to his death. We noted that Mr A's' sudden deterioration appeared to have been due to a rare cardiac problem that was unpredictable. However, Mr A did receive an overdose of iron and there was an error in his medication on discharge. Therefore, we upheld this aspect of Ms C's complaint and asked the board to provide evidence of action they said they had taken.

Ms C also complained about the nursing care Mr A received. We took independent advice from a nursing adviser. We found that the nursing care was reasonable and appropriate. Therefore, we did not uphold this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and her family for Mr A having received too high a dose of intravenous iron and the error in Mr A's medication on his discharge. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.