Health

Summary

Mr C attended Queen Elizabeth University Hospital for a hernia repair operation (an operation to correct a hernia, which is a bulging of internal organs or tissues through the wall that contains them) but complained that he was not properly advised of the risks. After the surgery Mr C suffered from significant bleeding and swelling and was discharged from hospital nine days after the operation. Mr  C returned a week later as he had to be readmitted for his wound to be cleaned and re-stitched. Mr C complained that both the medical and nursing care he received was unreasonable and that the board's communication with him was unreasonable.

We took independent advice from a consultant general and colorectal surgeon (colorectal surgey is the branch of surgery which deals with repairing the damage caused by disorders of the rectum, anus and colon) and from a registered nurse. We found that Mr C had signed a consent form which detailed the possible risks of surgery and did not uphold this aspect of Mr C's complaint.

In relation to the medical care received, we found that there had not been consultant involvement in Mr C's discharge and that he should have been followed-up afterwards given his significant complications. Therefore, we upheld this aspect of Mr C's complaint.

We found that Mr C's nursing care had been reasonable and that their records were clear and detailed. We did not uphold this aspect of Mr C's complaint.

Finally, we found that there was little documentation of an explanation for Mr C's complications, of the treatment options available and what he could expect. There was also no indication that Mr C had been provided with reasonable reassurance at a time when he was suffering understandable anxiety. We considered that communication with Mr C was unreasonable and upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to give proper consideration to his complications after surgery. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Where significant complications develop, patients should be offered an explanation and this should be documented.
• When significant complications develop after hernia surgery, an appropriate consultant should be involved in the decision to discharge and a follow-up appointment should be made.

Summary

Mr C, a patient adviser, complained on behalf of his client (Ms B) regarding the care and treatment provided to her father (Mr A) at Western Infirmary.

Mr A was an in-patient receiving dialysis (a form of treatment that replicates many of the kidney's functions) at the hospital for 12 weeks before he died. Ms B was concerned that Mr A did not receive appropriate dialysis treatment during the admission. We took independent advice from a consultant nephrologist (a  specialist in kidney care and treating diseases of the kidneys). They noted that the delivery of dialysis was difficult in this case because Mr A was frequently confused and unable to co-operate with the dialysis treatment. We considered that the records showed that Mr A received a reasonable number of dialysis sessions during the admission, and that the dialysis treatment prevented the toxins in his blood from reaching excessive levels. We found no evidence of failings in dialysis treatment, and we did not uphold this aspect of Mr C's complaint.

Ms B was also concerned that the board failed to take appropriate steps to ensure Mr A was comfortable and safe when receiving dialysis treatment. We took independent advice from a consultant in old age psychiatry and from a registered nurse. We considered that medical staff appropriately managed Mr A's delirium with the input from the hospital's old age psychiatry team. We found that the board had taken reasonable steps to help to ensure Mr A was comfortable when receiving dialysis and we noted that a number of fall risk assessments were carried out throughout the admission. The records showed that Mr A sustained a number of falls during the admission, and we were unable to conclude that the board followed their referral criteria for the hospital falls prevention co-ordinator. Although we were unable to conclude that earlier involvement from the hospital falls prevention co-ordinator would have prevented Mr A's third fall, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms B for the delay in referring Mr A to the hospital falls prevention co-ordinator. 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 at risk of sustaining a fall in hospital should be referred to the hospital falls prevention co-ordinator if they meet the board's referral criteria.

Summary

Mr C complained about the care provided to his late mother (Mrs A) by the practice. In particular, Mr C said the practice knew that his mother had cancer and had had chemotherapy. However, the family had concerns that on one occasion there was a failure to admit Mrs A to hospital and, on another, a GP had refused to make a home visit. When Mrs A was seen by a different GP the same day, she was admitted to hospital. Mr C felt that given his mother's medical history, the practice could have provided more appropriate care.

We took independent medical advice from a GP. We found that the GPs involved in Mrs A's care carried out appropriate assessments given the reported symptoms. On the first occasion, the GP had contacted the oncology (cancer) specialists for advice as Mrs A was experiencing the side effects of chemotherapy. At that time, it would not have been appropriate to have referred Mrs A to hospital due to the increased risk of her catching an infection from other patients who may have been unwell or from hospital acquired infections. On the second occasion, there was a change in Mrs A's symptoms from when the initial request for a home visit was made. As a result a home visit was arranged and Mrs A was appropriately admitted to hospital at that time. Therefore, we did not uphold Mr C's complaint.

Summary

Ms C complained about the care and treatment her mother (Mrs A) received at the practice. Mrs A had a history of a number of health issues and Ms C said that the practice failed to monitor her properly or to ensure that she saw a cardiologist (a doctor who specialises in diseases and abnormalities of the heart). She further complained that Mrs A's symptoms were not treated reasonably and the medication she was prescribed was inappropriate.

We took independent advice from a GP. We found that Mrs A had been regularly seen, review appointments had been arranged and the medication prescribed was reasonable. At a previous surgery, Mrs A was managed in secondary care (in a hospital by a cardiologist) who had the responsibility for ensuring her ongoing cardiology follow-up and monitoring. We found that the practice had noted that Mrs A had not been to a follow-up and they contacted the hospital to advise them as was appropriate. Therefore, we did not uphold Ms C's complaint.

Summary

Mr C complained that he was not made aware of the risk of having a skin-sensitive test before it was performed and that the board failed to ensure the test was carried out in a reasonable way. Mr C suffered from urticaria (hives) and he underwent a Minimal Erythema Dose (MED, short exposure to ultraviolet radiation) test to help inform phototherapy (light) treatment for the condition. Mr  C said that after the test he was left with scarring on his lower back.

We took independent advice from a specialist in dermatology (the branch of medicine concerned with the diagnosis and treatment of skin disorders). We found that there was evidence that the treatment was confirmed to Mr C and the possible side-effects were explained to him. We also found that Mr C signed the form saying the treatment and side-effects had been explained to him. Therefore, we did not uphold this aspect of Mr C's complaint.

In relation to how the test was carried out, we found that Mr C experienced a normal darkening of his skin as a result of the process and this was temporary. We also found that there was no evidence to show the test was carried out in an unreasonable way. Therefore, we did not uphold this aspect of Mr C's complaint.

Summary

Ms C complained about the care and treatment her late mother (Mrs A) received at Aberdeen Royal Infirmary. Mrs A had a history of a number of health issues and was admitted to the cardiology unit (the branch of medicine that deals with diseases and abnormalities of the heart) with a diagnosis of atrial fibrillation (a  heart condition that causes an irregular and often abnormally fast heart rate) and congestive heart failure. While she was in hospital, Mrs A had a heart attack but Ms C said that she was not told about this. She also said that Mrs A was not properly monitored nor given dialysis to reduce the fluid she retained. Mrs A's condition deteriorated and she later died.

We took independent advice from a consultant cardiologist. We found that Mrs  A's symptoms should have alerted staff to the possibility of internal bleeding and that neither the additional diagnosis of unstable angina (chest pain caused by reduced blood flow to the heart muscles) nor a management plan were documented. Therefore, Mrs A's emergency management plan could have been affected, however, it is unlikely to have changed her immediate outcome. There was also no evidence that Mrs A's deteriorating condition had been communicated to her family. Therefore, we upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to consider internal bleeding, to document the additional diagnosis of unstable angina and its management, and no evidence of deterioration being communicated to the family. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• All potentially important admission diagnoses should be clearly documented and updated in the light of investigation results and clinical review. A clear management plan should be written for each admission diagnosis especially where it may involve a change in medication or withholding of therapy, an invasive procedure or potential risk to a patient as in the case of acute coronary syndrome. Treatment options and discussions should be recorded.
• Changes in a patient's condition such as a deterioration as in this case should be appropriately communicated to relatives. Serial investigation results should be reviewed (and documented) against previous ones and against admission results.

Summary

Mr C complained that the practice failed to discuss the risk of testosterone replacement when it was prescribed to him.

We took independent advice from a GP. We found that at the start of his prescription, there was no evidence in Mr C's medical records to show that the risks and benefits of the treatment had been discussed with him as required by General Medical Council guidance. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to discuss the risks of testosterone therapy with him. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

Summary

Mr C was attending the endocrinology (the branch of medicine concerned with endocrine glands and hormones) department at Aberdeen Royal Infirmary for tests associated with his body's ability to make a natural steroid hormone. Several month's later he suffered a stroke and he believed that this was a result of him taking testosterone replacement therapy. Mr C complained that during a clinic attendance he was not warned about the risks and benefits of this therapy.

We took independent endocrinology advice. We found that Mr C had been prescribed testosterone replacement therapy by his GP and that it was the responsibility of the prescribing doctor to discuss the risks and benefits with him. When hospital clinicians became aware of the testosterone therapy, they contacted the GP practice to obtain more information and suggested a way forward. We considered this to be reasonable and did not uphold Mr C's complaint.

Summary

Ms C was admitted to Aberdeen Maternity Hospital as she had symptoms of preeclampsia (a pregnancy-related condition involving a combination of raised blood pressure and protein in the urine). Ms C complained about decision making in terms of induction of labour, and the care and treatment provided during her labour, including administration of opiate pain relief and the decision that it was appropriate to proceed with a vaginal delivery, rather than a caesarean section. Ms C's baby experienced breathing difficulties following birth, believed to be associated with the opiate pain relief Ms C received, and was cared for by the neonatal team for around five days before they were both discharged home. Ms  C also complained that the board's view that her baby's physical and mental development will not be affected by this was unreasonable.

We took independent advice from a consultant obstetrician and gynaecologist (a  doctor who specialises in pregnancy and childbirth as well as the female reproductive system). We found that it was reasonable to induce Ms C's labour in the circumstances of her case. The records indicated that appropriate discussions had taken place with Ms C and that she had taken the decision to proceed with induction. Therefore, we did not uphold this aspect of Ms C's complaint.

In relation to Ms C's concerns about care and treatment during her labour, we found that it was reasonable to provide opiate pain relief. We found that the guidance indicates that whilst morphine administration may have significant side effects for mother and baby, these side effects are considered to be short-term. We found that the board had already offered an apology to Ms C in relation to delays in obtaining blood test results and that they had taken steps to improve service in this area. We noted that the blood should have been sent urgently for testing but that the delays were unlikely to have had any bearing on the care and treatment that Ms C received. We also found that it was reasonable to proceed with vaginal delivery in the circumstances, particularly as Ms C's labour had progressed very quickly. However, Ms C's notes indicated that there was a plan made that day for her to have a caesarean section and that the board's local policy on preterm labour and birth indicated that steroids should have been administered as a result. We considered that, in line with the local policy, Ms C should have received steroids. Therefore, we upheld Ms C's complaint about the care and treatment during labour and made further recommendations in this connection.

We took independent advice from a consultant neonatologist (a doctor who specialises in the medical care of newborn infants, especially ill or premature newborns) in relation to the board's view that Ms C's baby would have no long- term effects from the breathing difficulties following birth. We found that the board's view was reasonable as there was no indication of any issues. 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 for failing to administer steroids in line with their local policy and that blood tests were not sent as urgent. 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 local policy should be followed regarding the administration of steroids. If policy is not followed, the reasons for this should be documented in the records. Patients awaiting blood tests for an emergency caesarean section or with severe preeclampsia in labour ward should have bloods sent as urgent.

Summary

Mr C complained about delays in the care and treatment he received for his eye at Dr Gray's Hospital and Aberdeen Royal Infirmary (ARI). Mr C had developed diabetic retinopathy (a complication of diabetes, caused by high blood sugar levels damaging the back of the eye, which can cause blindness if left undiagnosed and untreated). He also complained about the impact the delays had on his sight, which he said left him almost blind, and about the delay in his treatment following routine diabetic screening by the board at a local health centre.

We took independent advice from a senior consultant ophthalmologist (a  specialist in the branch of medicine concerned with the study and treatment of disorders and diseases of the eye). We found that there were delays in Mr C being seen following his initial appointment at Dr Gray's Hospital and following his original laser treatment at the hospital. It appeared that due to a failure in the booking system, the board failed to arrange a follow-up appointment for Mr C at ARI after his original laser treatment. The board accepted and apologised for this failing, and indicated that remedial action has been taken. However, we considered that further action should be taken by the board in this area and we addressed this in our recommendations. We upheld this part of Mr C's complaint.

In relation to the follow-up appointment's, we found that the delay contributed to him developing more severe diabetic retinopathy and the subsequent need for surgery. Although the surgery was successful, the poor clarity of vision that finally occurred was possibly not related to the delay and may have been due to other elements of diabetic retinopathy.

We also found that there was a long delay of over three months from Mr C's diabetic screening at the health centre to his laser treatment at ARI. This was outwith the timescales recommended and we considered that Mr C should have been seen within a shorter timescale. We noted it was difficult to determine whether the deterioration in Mr C's sight occurred as a consequence of the previous problems with diabetic retinopathy or whether this was a secondary event. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delays in his treatment following his initial appointment at Dr Gray's Hospital and following his diabetic screening at the health centre. 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 board should have a follow-up system that ensures patients are seen within an appropriate time frame; and appropriately followed up across different sites. The system put in place should also take into account relevant standards/guidelines.