Health

Summary

Mrs C complained about the treatment she received from the ambulance service. Mrs C said that she told the paramedic she had chest pains and had vomited a lot of blood. She said the paramedic refused to carry out a proper assessment and returned to their vehicle. Mrs C dialled 999 again and the paramedic returned to the house. The paramedic spoke to Mrs C's GP and it was arranged that she should make an appointment at the practice to discuss her health problems. Mrs  C made a further call to the ambulance service 12 hours later and was then taken to hospital.

We took independent advice from a consultant in emergency medicine. We found that there was a difference in recall between the paramedic and Mrs C about the amount of blood she had lost whilst vomiting. The paramedic had recorded that Mrs C had only coughed up a small streak of blood. If the paramedic's recall was the more accurate, then there was no requirement to take her to hospital. However, had she vomited a lot of blood as had described in the later call for assistance then a transfer to hospital was appropriate. While there was some contact between the paramedic and Mrs C's GP, the GP's phone note did not mention any blood loss.

On balance, we decided that in view of the record of little blood loss and the facts that the paramedic had made contact with the GP practice, Mrs C did not seek additional medical assistance for a period of 12 hours; and that her symptoms at that time were vastly different from before, that the actions of the paramedic were reasonable. We did not uphold the complaint.

Summary

Ms C complained that NHS 24 failed to provide her with an appropriate assessment of her condition and advice during a telephone call.

We took independent advice from a GP. We found that the questions asked by NHS 24 to assess Ms C's condition were reasonable and that there was no clinical indication for Ms C to be advised to attend A&E. We also noted that Ms  C was advised to see a pharmacist. We found that, ideally, Ms C should have been referred directly to the out-of-hours service, but it was not unreasonable or unsafe for Ms C to be advised to see a pharmacist. We did not uphold Ms C's complaint.

Summary

Mr C complained about the treatment he received from the board for pain in his thigh. Mr C said that he attended Perth Royal Infirmary and Ninewells Hospital over nearly a three year period for treatment for his condition and was seen by three different consultant vascular surgeons (a specialist in the treatment of diseases affecting the vascular system including diseases of the arteries, veins and lymphatic vessels). Mr C said he was not satisfied with the treatment suggested by the consultants and was subsequently seen and assessed by a surgeon at a private hospital, who carried out treatment which cured the pain in Mr C's thigh.

We took independent medical advice from a consultant vascular surgeon. We found that Mr C's treatment by the board was reasonable and found no failings in the treatment offered. Therefore, we did not uphold this part of Mr C's complaint.

Mr C also complained that the board failed to provide him with an adequate response to his complaint. We found that aspects of the board's response to Mr C's complaint did not appear to match with the evidence in the medical record and the response also failed to answer all Mr C's questions at the end of his letter of complaint. Therefore, we upheld this part of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure in complaint handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance

In relation to complaints handling, we recommended:

• Responses to complaints should take into account the evidence in the medical records and address all the issues raised, in accordance with the NHS Scotland Complaints Handling Procedure.

Summary

Mrs C complained that certain risks associated with knee replacement surgery she underwent at Ninewells Hospital had not been explained to her when she consented to the operation. She also complained that the wrong size of implant was used and that cement had leaked and caused nerve injury. Mrs C underwent additional surgery a couple of days later to remove the cement.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the recognised risk of some complications were not documented as having been explained to Mrs C in line with the General Medical Council's consent guidance. We considered this was unreasonable and upheld this aspect of Mrs C's complaint.

Whilst we could not say for certain what caused Mrs C's nerve damage (a recognised risk of surgery that was explained to her during the consent process), we considered it was unlikely to be related to the cement leakage. However, we were concerned about actions of staff in relation to the sizing of the implants and the lack of experienced staff present in the theatre at the time of implantation. 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 failing to inform her of all the recognised risks of the surgery, for the inappropriate circumstances around component sizing, lack of experienced staff in theatre and record-keeping failures. 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 should receive full information on the risks of surgery in accordance with recognised guidance such as the General Medical Council.
• Implant sizing is the operating surgeon's responsibility; and all relevant staff should ensure they are present in the theatre.
• Staff should ensure thorough and contemporaneous record-keeping of all relevant events during surgery.

Summary

Mrs C complained that the board unreasonably delayed in diagnosing secondary breast cancer. Following treatment for breast cancer, Mrs C underwent annual check-ups with a consultant surgeon where she complained of a lump and pain near her reconstructed breast (a breast that has been reshaped following a mastectomy (breast removal)). Mrs C said that these reports were not appropriately investigated.

We took independent advice from a specialist in breast cancer. We found that investigations were carried out when Mrs C first reported a lump near the reconstruction and that relevant guidelines did not recommend routine mammography (x-ray of the breast) of the reconstructed site and associated axilla (underarm). We considered that the board had practised within the national recommendations and Mrs C was followed up and examined regularly. We also found that when Mrs C presented with a new lump it was investigated and treated in a timely manner. We found that the standard of medical care was reasonable and there had not been an unreasonable delay in diagnosing the recurring cancer. We did not uphold the complaint.

Summary

Ms C complained that the board's response to her complaint was unreasonable and contained many errors.

We found that the board's response was an accurate reflection of their records of Ms C's treatment. The board explained why they could not delete entries from Ms C's medical records, and added Ms C's handwritten note to the records to reflect her view of events.

The board acknowledged that they could have provided Ms C with better information and support to make informed choices about ongoing treatment, and said they were sorry for this. Ms C chose to get private treatment as she was unhappy with the treatment she had received from the board and wanted the board to pay for this. The board offered Ms C different treatment options and consultations with different doctors but Ms C declined this offer. The board's response explained why, under the circumstances, they could not pay for Ms C's private treatment.

We considered that the board's response to Ms C was reasonable. Therefore, we did not uphold the complaint.

Summary

Mr C complained that his wife (Mrs A) had undergone open heart surgery at Edinburgh Royal Infirmary when she had been due to undergo a less invasive procedure. Following surgery, Mrs A was transferred to another hospital where she died shortly afterwards. Mr C said that his wife suffered from dementia and could not have understood the decision to change the procedure or have provided informed consent. Mr C noted he had welfare power of attorney and accompanied his wife to all her appointments. Mr C said that he had not been informed about the change of procedure. Mr C also complained that Mrs A was unreasonably discharged to another hospital. Mr C felt that Mrs A would have survived if she had been treated differently.

We took independent medical advice from a consultant cardiothoracic surgeon (a specialist who operates on the heart, lungs and other chest organs). We found that Mrs A's procedure was changed after an appropriate assessment of the risks of both types of surgical procedure and that it was reasonable to proceed with open heart surgery. There was no evidence that Mrs A's chances of survival were compromised by this decision. We also found that an assessment had been carried out which found that Mrs A had a mild memory impairment, however, medical staff were satisfied that she had the capacity to understand and consent to the change in procedure. We considered that this was reasonable. Therefore, we did not uphold these aspects of Mr C's complaint.

In relation to the hospital transfer, we found that this was unreasonable given Mrs  A's condition. We upheld this aspect of Mr C's complaint. However, we could not determine that Mrs A would have survived if this had not taken place.

In relation to the board's communication with Mr C and his family, we found that Mrs A had been in hospital for over a week prior to the procedure due to a chest infection and that Mr C had been present every day. We considered that the board should have discussed Mrs A's care when Mr C was present. Therefore, we upheld this aspect of Mr C's complaint. We noted that the board had acknowledged and apologised for this failing.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for unreasonably deciding to transfer Mrs A to another hospital before she had sufficiently recovered from surgery. 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:

• Review their policies and procedures for patient transfer to ensure that distance travelled is taken into account as part of the decision.

Summary

Mr C complained about the care provided to his wife (Ms A) during a home birth, in particular that two midwives did not attend at the same time.

We took independent advice from a midwife. We found that it was standard practice for one midwife to attend first and that the role of the second midwife is to assist in the event of an emergency requiring one-to-one care. We considered that there was no requirement for emergency care for either Ms A or their child, and therefore, no requirement for a second midwife to be present. We did not uphold this aspect of Mr C's complaint.

In the days after the birth, community midwives attended Mr C's home and following an incident, the board decided not to allow any further visits to Mr C's home if he was present. Mr C complained that this decision was unreasonable.

We found that the board's actions had been appropriate and the decision taken was reasonable based on the available information. Therefore, we did not uphold this aspect of Mr C's complaint. However, we considered that a further risk assessment should be undertaken in the event of any future pregnancies, to review the requirement for the restriction to remain in place, and we fed this back to the board.

Summary

Mrs C complained that the board unreasonably failed to make appropriate arrangements to deliver her baby by cesarean section (c-section) in line with her birth plan. Mrs C's waters broke two days before she was due to have her c- section at Wishaw General Hospital and she contacted the hospital for advice. Mrs C was told to return that evening and confirmed she still wished to have a c- section. After her arrival at hospital, Mrs C waited almost three hours before being clinically assessed. By the time she was examined she was 8cm dilated, and although staff started to prepare her for a c-section there was no theatre available and she progressed through labour, with her child eventually being delivered by forceps.

The board said that the department had been particularly busy, and that they had prioritised patients according to clinical need. Mrs C was unhappy with this response and brought her complaint to us.

We took independent advice from a consultant obstetrician (a doctor who specialises in pregnancy and childbirth). We found that there was no medical need to open a second theatre and that Mrs C and her baby has been appropriately monitored throughout the labour. However, Mrs C was on the 'red pathway' for her maternity care which highlights significant/obstetric risks and we found that there had been a delay in assessing her after her arrival at hospital. We considered that Mrs C should not have been left without adequate triage on her arrival at hospital. We upheld this aspect of Mrs C's complaint. However, we noted that the outcome may not have been different even if Mrs C had been examined sooner.

Mrs C also complained that the board's handling of her complaint was unreasonable. When Mrs C first raised her concerns with the board, she was offered a meeting with the consultant whose care she was under. At the end of the meeting the consultant suggested that Mrs C prepare a note setting out her account of what had happened. Mrs C understood she was making a formal complaint, but the consultant had actually asked for the account so that the Obstetric Risk Management Group could consider if a review of the case was required and identify any areas for learning. The misunderstanding came to light several months later, at which stage Mrs C was appropriately directed to the complaints process. Although we considered that the consultant had been acting in good faith, we were critical of the board's failure to identify Mrs C's concerns as a formal complaint. 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 the delay in assessing her. The apology should recognise the impact of her birth experience on her daily life.
• Apologise to Mrs C for failing to identify her concerns about her treatment as a formal complaint. The apologies should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leafletsand-guidance.

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

• Relevant staff should take a pro-active approach to triage, ensuring clinical questions are asked and documented.

In relation to complaints handling, we recommended:

• Staff should be confident in recognising complaints. In cases where there is any lack of clarity over whether concerns should be treated as a formal complaint, steps should be taken to ascertain and clearly record the wishes of the patient.

Summary

Mrs C complained about the medical and nursing care and treatment her late mother (Mrs A) received when she was admitted to Lorn and Islands Hospital. She also complained about the communication with her family and that the board had failed to handle her 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 it was difficult to provide an overall view about the medical care and treatment given to Mrs A due to the length and complexity of her admission. However, we found there had been a delay in diagnosing Mrs A's delirium and that she had a urine infection. We also found that the death certificate process was handled insensitively. Therefore, we upheld this aspect of Mrs C's complaint.

In relation to the nursing care given to Mrs A, we found no failings on the part of nursing staff regarding Mrs A's dehydration, dietary intake and her personal care. Therefore, we did not uphold this aspect of Mrs C's complaint.

In relation to communication, we found that the nursing communication was reasonable. However, we found that there was a delay in medical staff communicating the results of a CT scan and the overall assessment of Mrs A's health to Mrs C. Therefore, we upheld this aspect of Mrs C's 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 Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in clinical care, communication and complaint 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 be aware of the potential for elderly patients to have delirium. Staff should be careful and sensitive with the death certification process and junior doctors should have senior supervision of this process as set out in national guidance.
• Families or carers should be involved in identifying delirium. Results of CT scans and the overall assessment of a patient's health should be communicated timeously to families.

In relation to complaints handling, we recommended:

• Complaints should be dealt with in accordance with the complaints handling process.