Health

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.

Summary

Mrs C complained about the practice's handling of a phone call made by her late son (Mr A) who had hurt his back. Mr A spoke with a triage nurse, who offered him an appointment with an Extended Scope Practitioner (ESP - a physiotherapist who can undertake extra duties such as ordering investiations or making referrals), which Mr A declined. The triage nurse advised Mr A to take regular paracetmol and ibuprofen, and to seek further assistance if his condition worsened. His request for stronger pain killers and other medication was declined. Mrs C considered that Mr A should have been seen by a GP and complained that Mr A didn't get the help he needed.

We took independent advice from a GP and a nurse. We found that the offer of an appointment with the ESP was reasonable for the assessment of back pain, and that it would have allowed for onward referral to a GP if deemed necessary. We also found that the triage nurse carried out a reasonable assessment and recorded no information that indicated the need for a GP assessment. Therefore, we did not uphold Mrs C's complaint.

Summary

Ms C complained that her prescribed medications had been mismanaged by the practice. She said that her medications were rarely available to collect from her local pharmacy after she had ordered them through the practice. Ms C said that she had been without key medication due to these access problems.

We took independent advice from a GP. We found that the practice prescribed Ms C's blood pressure medication regularly, however, we could not say whether this was provided within a reasonable time of Ms C's requests because there was insufficient evidence available. We also found that the practice was not unreasonable in failing to prescribe an updated contraception medication because they were not notified of the change prior to the medication being issued. Therefore, we did not uphold this aspect of Ms C's complaint.

Ms C also complained that the practice refused to take complaints by phone and did not respond to complaints made in writing. Ms C submitted two complaints. We found that the tone used by the practice in their response was confrontational, did not recognise the inconvenience Ms C had experienced, and did not reflect on whether there was learning to be taken from the complaint. We also found that Ms C was given no information about the complaints process and was not told whether she could escalate her complaint, either to stage two of the complaints process or to our office. In responding to the second complaint, there was no acknowledgement that Ms C had not received the previous response, despite it being clearly mentioned to them. We considered that the practice's responses to Ms C's complaints were unreasonable. Therefore, we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to provide reasonable responses to her complaint and for the inappropriate tone and content of their letters responding to her complaints. The apologyshould meet the standards set out in the SPSO guidelines on apology availableat www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• The practice must have a complaints procedure in place which meets the requirements of the NHS model complaints handling procedure and the Patient Rights (Scotland) Act 2011.
• The practice must ensure that staff respond to complaints fully, in a timely manner and any responses should remain respectful at all times.

Summary

Mrs C complained about the clinical treatment which she received at Dumfries and Galloway Royal Infirmary. She had undergone surgery for a leg fracture and she said she was informed by a consultant that the wrong size of screws had been used to fix the fracture. Mrs C felt that her recovery period following the surgery was too long and this was due to the error with the screws used to hold the fracture.

We took independent advice from an orthopaedic consultant (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the screws which had been used sat slightly differently than would be expected but they were not excessively long. Mrs C had suffered a very significant injury and that would have accounted for her ongoing pain and mobility issues. The screws would have been contributing to the discomfort, however, to a lesser extent than the injury itself. We did not identify any failings in the treatment. Therefore, we did not uphold Mrs C's complaint.

Summary

Mrs C complained that the board failed to carry out her total knee replacement appropriately in Dumfries and Galloway Royal Infirmary. Mrs C suffered pain and stiffness after the operation and eventually had to have a revised total knee replacement at another hospital.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). Although there was evidence of malalignment (incorrect or imperfect alignment) of the knee on the x-rays and CT scan carried out some time after the operation, a few degrees of variation would not be unusual. This was unlikely to have contributed to the stiffness Mrs C experienced. We found that that without the benefit of hindsight, there was no evidence that the operation had not been reasonably carried out. Therefore, we did not uphold this aspect of Mrs C's complaint.

Mrs C also complained that the care and treatment provided to her after the operation was unreasonable. We found that, in general, the care and treatment provided to Mrs C after the operation was reasonable. However, we found that a letter the board issued to the hospital where she had the revised total knee replacement contained a number of inaccuracies. For this reason, we upheld this aspect of Mrs C's complaint.

Finally Mrs C complained that the board refused to lend her a continuous passive motion (CPM) machine. We found that it would not be routine for a patient to be given a CPM machine. We found that the board's actions in relation to this matter were reasonable. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C that their referral letter to another hospital contained inaccuracies. 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:

• Referral letters should be accurate.

Summary

Mr C complained about the treatment he received for an injury to his achilles tendon (a band of connective tissue joining the heel bone to the calf muscle) at Dumfries & Galloway Royal Infirmary. In particular, Mr C considered that there was a delay in referring him for surgery to repair his achilles tendon. Mr C also complained that, after his surgery, he was not given appropriate treatment for the problems he experienced with the surgical wound.

We took independent advice from a consultant orthopaedic and trauma surgeon (a doctor who diagnoses and treats a wide range of conditions of the musculoskeletal system). We found that it was reasonable that Mr C was initially given conservative (non-surgical) treatment for his injury, by way of a cast. We did not consider there was an unreasonable delay in referring Mr C for surgery on his achilles tendon. The adviser explained that Mr C was at particular risk of the surgical wound being slow to heal. We considered that the treatment Mr C received for his difficulties with the wound was reasonable.

We did not uphold Mr C's complaints.

Summary

Mr C complained that his shoulder dislocations went undiagnosed for around eight months after he attended the emergency department on a number of occasions at Crosshouse Hospital and during an in-patient stay. After Mr C's shoulder dislocations were identified at an orthopaedic (the branch of medicine specialising in the treatment of diseases and injuries of the musculoskeletal system) clinic appointment, he underwent shoulder replacement surgery. Mr C also complained that he was not informed about heart problems he experienced whilst he was an in-patient and that the board failed to handle his complaint appropriately.

We took independent advice from a consultant in emergency medicine and a consultant in acute medicine. We found that the board had acknowledged that Mr C's injury should have been picked up during his admission and had apologised to him. The board also took steps to share Mr C's case with medical staff for learning and improvement. However, we found that there was no evidence to demonstrate that Mr C's shoulders had been examined on one occasion when he had attended the emergency department.

In terms of Mr C's concerns that he was not informed about the heart problem he suffered during his admission, we found that there was no records to show that this had been explained to him and understood given he had memory loss.

In relation to the board's handling of Mr C's complaint, we found that the board took ten months to respond. We acknowledged that Mr C's case was complex, however, we considered that this delay was unreasonable. We also found that the board took four months to arrange a meeting to discuss his complaint and that the written response lacked detailed explanation. We upheld all of Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to examine his shoulders and failure to discuss with him and document the heart problems he had during his admission. 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 attending the emergency department should receive a full assessment of their presenting symptoms.
• Staff should ensure that a patient's care is fully explained and that such discussions are clearly recorded in the clinical records.

In relation to complaints handling, we recommended:

• Complaint meetings should be arranged in a timely manner; and written responses should provide sufficient explanation and address all the points raised in line with the NHS Complaints Handling Procedure.

Summary

Ms C and Ms C raised their concerns about the care and treatment their late mother (Mrs A) received when she was admitted to University Hospital Crosshouse, in particular, about the clinical and nursing care and treatment Mrs A received. They also complained about the communication with their family and that the board had failed to handle their complaint in a reasonable way.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a nursing adviser. We found that there had been a failure to identify how unwell Mrs A was and a delay in initiating a higher level of care. We considered that the clinical care Mrs A received was unreasonable and upheld this complaint. However, we noted that it was possible that Mrs A would have died even with appropriate care, given the severity of her illness.

In relation to the nursing care given to Mrs A, the board acknowledged that Mrs A would have found it difficult to use the call system. As a result of a fall that Mrs A had suffered, the board staff had been advised that all patients with any degree of cognitive impairment should not be left unassisted within the ward where they could not been directly seen by nursing staff. We were satisfied with the action taken by the board. We also found no failings on the part of nursing staff regarding Mrs A's dehydration and dietary intake, medicine administration and Mrs A's personal care. Therefore, we did not uphold this aspect of the complaint.

In relation to communication, while we found there was evidence of some good communication, we found that overall the communication was poor, particulary after it was clear to medical staff that Mrs A's condition had deteriorated. We also found failings in relation to the communication surrounding the Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision. Therefore, we upheld this aspect of the complaint.

Finally, in relation to complaint handling, we found that the board had failed to comply with their complaints handling procedure and we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to the family for the failings in clinical care, communication and complaints handling. 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 recognise signs of deterioration in patients and actively manage this.

In relation to complaints handling, we recommended:

• Written responses should normally be sent within 20 working days of receipt of the complaint, or a revised timescale agreed with the complainant.