Health

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.

Summary

Mr C complained that NHS 24 failed to handle his call appropriately. Mr C initially phoned 999 to request an ambulance for his wife (Mrs A). However, it was deemed that an ambulance was not required and Mr C was referred to NHS 24 for a further assessment of Mrs A's symptoms to be carried out. Mr C complained to NHS 24 about the call handler's line of questioning and their refusal to send an ambulance. NHS 24 acknowledged the call could have been handled better. Mr  C was unhappy with this response and brought his complaint to us.

We took independent advice from a nursing adviser who reviewed the case records and the audio recording of the call. We found that the call handler should have been more flexible in their questioning and they could have been more empathetic and understanding of Mr C's frustration. We upheld the complaint and asked NHS 24 to provide an update on the learning and improvement they had already identified.

Summary

Ms C, an advocacy worker, complained on behalf of her client (Ms A) about the care and treatment provided by the practice. Ms C complained that there had been unreasonable delays in the diagnosis of Ms A's bladder cancer and that a urology referral should have been made earlier.

We took independent advice from a GP. We found that the referral to urology (the branch of medicine that specialises in the male and female urinary tract, and the male reproductive organs) had been made at the appropriate point and that the care provided to Ms A was reasonable for the symptoms she reported across the period covered by the complaint. We did not uphold Ms C's complaint.

Summary

Ms C complained about the treatment she received at the Royal Infirmary of Edinburgh. Ms C had a contraceptive device fitted and a number of months later she developed a number of symptoms including body aches, severe period pain, headaches and joint pain. Ms C only has one fallopian tube (either of a pair of tubes along which eggs travel from the ovaries to the uterus) and understood that the device should not have been fitted in patients with only one fallopian tube. Ms C complained about this and that she was not given anaesthetic during the procedure.

We took independent advice from a consultant gynaecologist (a doctor who specialises in the female reproductive system). We found that although the information about the device does caution against patients with only one fallopian tube, it does not give specific reasons why this is so. There was no clinical reason why the device could not be used in Ms C's circumstances. We also found that adequate consent was obtained along with an explanation of the possible side effects which could be encountered. There was also no requirement for an anaesthetic as it was not a surgical procedure. Therefore, we did not uphold Ms  C's complaint.

Summary

Miss C complained about the care and treatment she received at the Western General Hospital. Miss C had a history of breast cancer and at a routine examination a member of staff noticed some discolouration of the skin around the breast. Miss C was told by staff that they felt she may have dermatitis (a skin condition) and an urgent referral was made to the dermatology department (the  branch of medicine concerned with the diagnosis and treatment of skin disorders). Miss C was subsequently told that she had angiosarcoma (cancer of the inner lining of blood vessels, commonly found in the skin, breast, liver, spleen and deep tissue). Miss C felt that it was unreasonable that staff had thought she had dermatitis and by referring her to dermatology there was a delay in the treatment of her returning breast cancer.

We took independent advice from a medical adviser. We found that Miss C's original breast cancer had not returned and that she had developed a rare but recognised complication of breast cancer treatment, angiosarcoma. In its early stages, this can often look like dermatitis or bruising. We found that staff acted appropriately by arranging an urgent dermatology review with investigations which resulted in the correct diagnosis. There was no evidence of any undue delay in the diagnosis. Therefore, we did not uphold Miss C's complaint.

Summary

Ms C complained about the care and treatment her husband (Mr A) had received at St John's Hospital following a suicide attempt. Ms C complained that Mr A was inappropriately given diazepam (a medicine used to treat anxiety), as it can be addictive.

We independent advice from a consultant psychiatrist. We found that it might have been appropriate to have given Mr A diazepam on a short term basis but the reason for prescribing it to him was not recorded. We found that when Mr A self-discharged from the hospital, there was a failure to carry out and/or document an appropriate suicide risk assessment. There was no evidence that medical staff considered detaining Mr A. There was also no evidence that they signposted him to any other sources of support or carried out any contingency planning in case his condition or level of risk to himself changed. In addition, we found that a junior medical staff member was not able to reach a senior colleague by phone for advice. Therefore, we upheld this aspect of Ms C's complaint. We also found that the board had not handled Ms C's complaint regarding the diazepam appropriately and we made a recommendation in relation to this.

Ms C also complained that there was a failure to provide Mr A with appropriate follow-up care after he self-discharged from the hospital. Mr A had been offered a follow-up appointment in two months' time. When he was unable to attend that appointment due to his poor mental health, he was offered an appointment for six months later. We found that Mr A was not given follow-up care that was appropriate to his needs, and that, in the circumstances, Mr A should have been offered an appointment within a week of him leaving the hospital. When Mr A could not attend that appointment due to poor mental health, he should have been offered a review at home. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide Mr A with reasonable care and treatment, for failing to provide him with appropriate follow-up care and for the inaccuracy in responding to her complaint. 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 reason for prescribing any medication, including one-off doses, should be clearly recorded.
• If a patient wishes to self-discharge and it is unplanned, there should be adequate processes in place, and adhered to, to manage this. This should involve carrying out appropriate risk assessments, appropriately signposting patients and/or carers to crisis services and carrying out contingency planning.
• Junior medical staff should have adequate supervision from senior medical staff, especially out of hours, and reliable mechanisms should be in place so they can contact senior colleagues for advice.
• Patients should receive follow-up care that is sufficiently timely and robust, which is appropriate to their individual needs. If patients are unable to attend their out-patient appointment, the board should consider alternative arrangements such as home visits.

In relation to complaints handling, we recommended:

• The board's complaints handling system should ensure that accurate responses are issued, which are based on the evidence gathered during their investigation.