Health

Summary

Ms C complained about the care and treatment provided to her mother (Mrs A) when she attended Queen Elizabeth University Hospital for a graft repair of a brain aneurysm (a procedure in which a catheter is passed through a small cut in the groin area to an artery and then to the blood vessel in the brain where the aneurysm (a bulge in the blood vessel wall) is located in order to repair it using coils (spirals of wire) which stabilise the aneurysm). Ms C complained that there had been complications and that there was a delay in the vascular team (specialists in the treatment of diseases affecting the vascular system including diseases of the arteries, veins and lymphatic vessels) coming to assist with the repair. Ms C also said that during Mrs A's recovery, the vascular team had not reviewed Mrs A.

We took advice from a consultant in interventional neuroradiology (a specialist in minimally invasive image-based technologies and procedures used in diagnosis and treatment of diseases of the head, neck, and spine) and a vascular surgeon. We found that the graft repair of brain aneurysm procedure was carried out reasonably, and the leakage of blood where the blood vessel had been closed is a well recognised complication of this procedure. We found that the complication had been managed in a timely and appropriate way, and that the care provided to Mrs A after her surgery was reasonable. However, we found that consent for the graft repair of brain aneurysm had only been taken on the day of surgery. We considered that this should have occurred earlier in order to allow Mrs A to fully understand the procedure and risks. We also found that there was no evidence that Mrs A had been provided with an information leaflet prior to the surgery. Finally, we found that the management plan after the procedure was not adequately communicated to the relevant team. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A that the consent process was not initiated at an earlier point than on the day of the procedure, that she was not provided with an information leaflet prior to the procedure, and that the management plan after the procedure was not adequately communicated to the relevant team. 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 consent process for graft repair of a brain aneurysm should be initiated at an earlier point than on the day of the procedure (unless there is an emergency situation) and information leaflets should be provided at the appropriate time.
• The plan regarding which team are responsible for the patient should be clear.

Summary

Mrs C complained about the medical care and treatment her late mother (Mrs A) received when she attended the emergency department at Queen Elizabeth University Hospital. Mrs C said that no blood or blood gases tests were carried out before Mrs A was discharged.

We took independent advice from a consultant in emergency medicine. We found that there had been no indication to carry out blood or blood gases tests when Mrs A had attended the emergency department and that the care and treatment she received had been reasonable. Therefore, we did not uphold the complaint.

Summary

Mr C complained about the board's treatment of his Basal Cell Carcinoma (BCC, a type of skin cancer). Having undergone three initial operations to remove a BCC, he required a further operation to remove a recurrence around nine years later. Mr C complained that the board failed to treat him properly when they initially carried out the surgery.

We took independent advice from a consultant dermatologist (a doctor who specialises in the diagnosis and treatment of skin disorders).

We found that the pathology report of the third procedure should have raised concerns that the tumour may recur. We noted that Mr C had been offered a follow-up appointment, but did not seem to have been warned of the possibility of recurrence. We considered that reasonable treatment options following the pathology from the third procedure would have included consideration for Moh's surgery (surgery where thin layers of cancer-containing skin are progressively removed and examined until only cancer-free tissue remains) and/or follow-up in one to two years with the warning that the tumour could return.

The board confirmed that following the third procedure, Mr C was reviewed then discharged to his GP two months later. We found that there was no record on file that he was advised the tumour may return. There was also no record of the board having considered treatment with Moh's microsurgery, although they confirmed that it was available at the time in question. Therefore, we upheld Mr  C's complaint.

Although we upheld the complaint, we noted the board's comments that had they provided a longer follow-up over two years, this would not have detected or prevented the later occurrence of the BCC. We accepted that it was unlikely this would have detected the recurrence. We also noted that there was no evidence that the surgeries were carried out incorrectly or that they contributed to the recurrence.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to consider possible Moh's microsurgery treatment, to arrange an appropriate timeframe for follow-up and to advise of the risk of recurrence of the tumour. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

Summary

Mrs C complained about the care and treatment that her child (Child A) received from the orthopaedic department (the branch of medicine that deals with diseases and injuries of the musculoskeletal system) and the rheumatology department (the branch of medicine that deals with rheumatism, arthritis, and other disorders of the joints, muscles, and ligaments) at the Royal Hospital for Sick Children, Yorkhill.

We took independent advice from a consultant spinal surgeon and a rheumatologist. We found that:

Mrs C was not informed that the possibility of a spinal x-ray had been discussed following Child A's appointment with the orthopaedic department.

there was no record of the referral that the orthopaedic department made to physiotherapy.

there was no record of the discussions within the orthopaedic department about the risk of doing an x-ray on Child A's spine.

there was no record of the referral that physiotherapy made to rheumatology.

the plan to watch Child A's back for changes did not happen.

We upheld Mrs C's complaints about the care and treatment provided following Child A's referral to the orthopaedic department and the rheumatology department.

Mrs C also complained about the way the board handled her complaint. We found that the board failed to acknowledge Mrs C's complaints in writing within three working days and failed to keep Mrs C updated about the reason for the delay in responding to her complaints and provide a revised timescale for a response. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and Child A for failing to provide Child A with reasonable care and treatment following their referral to the orthopaedic department and the rheumatology department, for failing to communicate reasonably with Mrs C and for failing to handle Mrs C's complaint reasonably. 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 and/or their parent/guardian should be informed when an x-ray is being considered following the identification of scoliosis (abnormal lateral curvature of the spine).
• Clear records of inter-disciplinary referrals and discussions should be kept.
• Clear records should be kept of discussions about the risk of performing an x-ray on a child's spine.
• Clear records of inter-disciplinary referrals and discussions should be kept.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the model complaints handling procedure. The model complaints handling procedure and guidance can be found here: www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs.

Summary

Having been diagnosed with lung cancer, Mrs C complained that she had been attending the practice for years with breathlessness and she considered that she should have been referred for specialist investigation sooner. The practice noted that Mrs C was fully investigated for intermittent complaints of breathlessness, and that she was diagnosed with chronic obstructive pulmonary disease (COPD - a disease of the lungs in which the airways become narrowed). The practice said that when Mrs C presented with new symptoms (a nocturnal cough along with worsening breathlessness) she was promptly investigated and the diagnosis of lung cancer was made. They did not consider there were previously any suggestive symptoms that might have prompted an earlier referral for suspicion of cancer. They noted that the grading of the cancer indicated it had been detected relatively early, and they considered that her COPD was the more likely source of her breathlessness.

We took independent advice from a GP. We found that it was reasonable for the practice to have made a presumptive diagnosis of COPD and that they sought to manage this within the primary care setting. The adviser said that the practice could have considered requesting a chest x-ray and respiratory referral around ten months earlier than they did, as Mrs C had reported worsening breathlessness (not just on exertion but also at rest). However, the adviser did not consider it unreasonable for them not to have taken that approach. They noted Mrs C was referred for breathing tests at that time, which confirmed the COPD diagnosis. On balance, we did not uphold the complaint.

Summary

Mr C complained about the care and treatment he received from the ear, nose and throat (ENT) service at Inverclyde Royal Hospital. Specifically, that he was not examined thoroughly and that staff were dismissive of his symptoms being related to sinusitis (inflammation of the lining of the sinuses).

We took independent advice from a consultant ENT surgeon experienced in treating cases requiring sinus surgery. We found that Mr C's symptoms had been appropriately investigated, in particular with CT scans (a scan that uses x-rays and a computer to create detailed images of the inside of the body) and endoscopy (direct visualisation by camera). There was no evidence to show that Mr C had bacterial or fungal sinusitis or any evidence of a sinus tumour. We considered that Mr C's care and treatment was reasonable and appropriate and did not uphold his complaint.

Summary

Mr C complained about the medical care and treatment that his wife (Mrs A) received from the board. Mrs A had a diagnosis of cancer and had a number of admissions to Aberdeen Royal Infirmary over a two month period. We took independent advice from a consultant clinical oncologist (a doctor who specialises in the diagnosis and treatment of cancer). We found that:

• Mrs A was discharged from hospital before the results of a stool sample were obtained and while she was experiencing diarrhoea
• there are no written records of the phone calls that the doctor had with Mrs  A or her GP following a positive result for Clostridium difficile (a bacterium that causes diarrhoea and more serious intestinal conditions)
• Mrs A was not readmitted to hospital as soon as the Clostridium difficile result became available.

We considered the medical care and treatment to be unreasonable and upheld this aspect of Mr C's complaint.

Mr C also complained about the nursing care and treatment that Mrs A received. We took independent advice from a nursing adviser. We found that:

• the board's response in relation to hand gels was inaccurate in that hand gels are ineffective when caring for patients with Clostridium difficile
• Mrs A's personal hygiene requirements were not recorded consistently and daily records were not kept to indicate what personal hygiene assistance Mrs A had received or had been offered
• nursing staff did not appear to adhere to the Infection Control Policy.
• nursing staff did not record how they knew about Mrs A's shingles (a viral infection that causes a painful rash) diagnosis or whether this information had been passed on to the admitting doctor.

We considered the nursing care and treatment to be unreasonable and upheld this aspect of Mr C's complaint.

Mr C also complained that the board did not handle his complaint reasonably. We found that the board failed to keep Mr C updated about the reason for the delay in responding to his complaint and to provide a revised timescale for completion. We also found that the board's complaint response did not address all the points that Mr C raised. 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 failure to provide Mrs A with reasonable medical and nursing care and treatment and for failing to handle his complaint reasonably. 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:

• Nursing staff should be aware that alcohol based hand rubs or hand gels are ineffective in removing Clostridium difficile spores and that hand-washing is an important aspect of preventing the spread of Clostridium difficile.
• Personal hygiene requirements should be recorded clearly and consistently. There should be daily recordings to indicate what personal hygiene assistance patients have received or have been offered.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the model complaints handling procedure. The model complaints handling procedure and guidance can be found here: www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs.

Summary

Mr C had been in contact with mental health services for a number of years and was informed by his current psychiatrist (a medical practitioner who specialises in the diagnosis and treatment of mental illness) that he had a diagnosis of borderline personality disorder. Mr C complained that his previous psychiatrist had failed unreasonably to diagnose him with this and provide the appropriate treatment.

We took independent advice from a medical adviser. We found that the standard of communication in relation to the diagnosis was unreasonable and that this led to uncertainty and distress for Mr C. While, we did not find this had an adverse effect on his management or treatment, we recognised that not learning of his diagnosis until recently lead to a great deal of uncertainty and distress. On balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings in record-keeping and communication. 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 clinician involved should reflect on this complaint and findings at their next appraisal.
• The board should ensure that clinicians follow the relevant guidance when diagnosing and discussing personality disorders with patients.

Summary

Ms C, an advocacy and support worker, complained on behalf of her client (Mrs  A) about the medical and nursing care and treatment Mrs A received when she was admitted to Aberdeen Royal Infirmary. Ms C also complained about Mrs  A's discharge, delays in receiving a neuropsychology (the study of the relationship between behaviour, emotion, and cognition on the one hand, and brain function on the other) assessment and neurosurgery (surgery on the nervous system, especially the brain and spinal cord) follow-up and that the board had failed to respond to her complaint in a reasonable way.

We took independent advice from a consultant neurosurgeon and a nursing adviser. We found that both the medical and nursing care and treatment given to Mrs A was reasonable. We did not uphold these aspects of Ms C's complaint.

In relation to Mrs A's discharge, we found that Mrs A had been medically fit for discharge and that nursing staff had reasonably managed the discharge planning. However, the board accepted that there had been a failure to provide appropriate information and literature to Mrs A and her family on discharge and had taken action as a result of these failings. We upheld this aspect of Ms C's complaint.

In relation to Mrs A's neuropsychology assessment, we found that there had been a delay in arranging this. We also found that Mrs A was not advised of the progress of her neurosurgery follow-up appointment when the timescale was not met. Therefore, we upheld these aspect of Ms C's complaint.

Finally, we found that the board had failed to comply with their complaints handling procedure and we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for the delay in providing a neuropsychology assessment, failing to update her on her neurosurgery review appointment and for the failings 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.

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

• Patients should receive a neuropsychology assessment, as part of post head injury follow-up, in a timely manner.
• Patients waiting on review appointments with the neurosurgery department should be updated on the progress of their appointments.

In relation to complaints handling, we recommended:

• Complaints should be dealt with in accordance with the complaints process, including that all issues raised in complaints should be addressed.

Summary

Ms C complained to us about the treatment she received from her dentist. She said that the dentist had damaged the cartilage in her jaw and it was causing her severe pain. When Ms C reported this to the dentist she was advised to stay on a soft diet and that she would be referred to dental consultants should the problem remain.

We took independent advice from a dentist. We found that there was no evidence that the treatment the dentist had provided was inappropriate or that it was the cause of the jaw problems. We found that Ms C had reported problems with her jaw a number of years previously but that no remedial action was required at that time. We found that the advice given by the dentist was reasonable and appropriate. Therefore, we did not uphold the complaint.