Health

Summary

Mr C complained about the care and treatment provided to his late father (Mr A) when he was admitted to Hairmyres Hospital with a suspected chest infection. Mr A was fed via a Percutaneous Endoscopic Gastrostomy (PEG, a tube into the patients's stomach through the abdominal wall) and early in the morning, on the day after his admission, Mr A's PEG became detached. While it appeared that nurses noticed this, it was not reported until a ward round later that day. By then, the entry tract had closed and the feeding tube was unable to be reinserted.

Subsequently, there were difficulties in ensuring Mr A's nutrition and there were numerous failed attempts to re-establish his feeding. After ten days, Mr A's family requested that he be transferred to another hospital to have a PEG surgically inserted but the procedure had to be stopped. Mr A died shortly afterwards. Mr  C complained that staff failed to act when the PEG had become detached.

We took independent advice from a consultant in general medicine. We found that the board's guidance stated that if a gastronomy feeding tube fell out, it should be replaced as soon as practicable, preferably within two hours. However, this did not happen and staff were initially unaware of the need to reinstate the PEG within a particular time frame. We also found that there was a lack of coordination and planning around the repeated failure to obtain a consistent route of feeding and there was a lack of communication about how unwell Mr A was. Although the outcome for Mr A may have been the same, we considered that his recovery was compromised by a level of care that fell below what could have been expected. 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 provide Mr A with a reasonable level of care in that his PEG tube was not quickly replaced and that there was a failure to initiate alternative methods of feeding. 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:

• Staff should be aware of and adhere to the board's policy on Enteral Tube Feeding, Best Practice Statement for Adults. Patients in a similar situation should receive a timely and feeding regime commenced and timely consideration of transfer. Record-keeping by doctors should meet General Medical Council standards.

Summary

Ms C, an advocacy worker, complained on behalf of her client (Ms A) about the care and treatment provided by the board in relation to a respiratory (breathing) condition. Ms C complained that Ms A had been unreasonably discharged from the care of a lung specialist when the specialist left the board. She also raised concerns about the medical and nursing care provided when Ms A was admitted to Hairmyres Hospital. Finally, Ms C complained that the follow-up Ms A received at Monklands Hospital was unreasonable and that the board's response to the subsequent complaint was unreasonable.

We took independent advice from a respiratory consultant. We found that as Ms  A's condition was stable, it was reasonable to discharge her when the lung specialist left the board. The discharge letter provided advice to Ms A's GP that if her symptoms progressed, she should be re-referred as a new patient. We also found no failings in the medical care and treatment that Ms A received either as an in-patient or in follow-up as an out-patient. Therefore, we did not uphold these parts of Ms C's complaint.

We took independent advice from a nursing adviser in relation to Ms A's concerns about nursing staff. We found that the nursing care that was provided to Ms A was reasonable. We did not uphold this part of Ms C's complaint.

Finally, we found that the response to Ms A's complaint was reasonable and considered that it addressed the points listed in her original complaint. Therefore, we did not uphold this part of Ms C's complaint.

Summary

Mr C complained about the medical care and treatment his late mother (Mrs A) received at Hairmyres Hospital. In particular, Mr C complained that a biopsy was not carried out and that the board had failed to give Mrs A an appointment for a ring pessary (a device used to support the uterus, vagina, bladder or rectum) change.

We took independent advice from a consultant gynaecologist (a doctor who specialises in the female reproductive system). We found that there had been no indication to carry out a biopsy when Mrs A attended the hospital following a referral from her GP. Therefore, we did not uphold this aspect of Mr C's complaint.

In relation to Mr C's concern that Mrs A had not been given an appointment for a ring pessary change, we found that the board had initially advised Mr C that this was as a result of a system failure. However, they later clarified that this was not the case. We found that the failure to attend an appointment for a ring pessary change was not caused by a failing on the part of the board and we did not uphold this aspect of Mr C's complaint. However we were concerned that incorrect information had initially been given to Mr C about this matter and made a recommendation to the board.

Recommendations

In relation to complaints handling, we recommended:

• Complaint responses should be accurate and issues raised should be thoroughly investigated.

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.