Health

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.

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.