Health

Lanarkshire Primary Care NHS Trust

Tayside Primary Care NHS Trust

Summary

Mrs C complained about the care and treatment that her father (Mr A) received from Dumfries and Galloway NHS Board (the Board) in A&E and in the clinical assessment unit at Dumfries and Galloway Royal Infirmary.  Mr A arrived at A&E late in the evening on 2 December 2017.  Early in the morning on 3 December 2017, Mr A was admitted to the clinical assessment unit.  While in the clinical assessment unit, Mr A had a cardiac arrest and he sadly passed away.  The cause of Mr A’s death was a ruptured abdominal aortic aneurysm (AAA).

Mrs C complained that Mr A’s symptoms were not investigated appropriately in A&E.  Mrs C also questioned whether the Board’s record-keeping regarding Mr  A’s care and treatment was appropriate.

We took independent advice from a consultant in emergency medicine, a consultant in acute medicine and a nursing adviser.

We found that the history and initial examination carried out in A&E were reasonable.  However, we also found that the Board failed to perform an ultrasound scan or a CT scan of Mr A’s abdomen in A&E to confirm or exclude a diagnosis of an AAA.  If a scan had been done in A&E this may have led to an earlier diagnosis of AAA, Mr A’s transfer to a hospital with a vascular surgical capability (vascular specialists treat disorders of the circulatory system) and the chance of his survival may have been greater.

We found that Mr A was not reviewed promptly by medical staff on his transfer to the clinical assessment unit when he was suspected to have an infection and the nursing documentation and cardiac arrest documentation were not completed reasonably.

In view of these failings, we upheld Mrs C’s complaint that the Board did not provide reasonable care and treatment to Mr A.  We also found that the failings in care that our investigation identified could have and should have been established and acted upon during the Board’s own complaints investigation. 

Mrs C also complained that the Board did not communicate reasonably with Mr  A’s family.  We found that Mr A’s family were not kept updated about his deteriorating condition, they were informed in a corridor that he had passed away and clear information was not given about the time of Mr A’s death.

In light of this, we upheld Mrs C’s complaint that the Board did not communicate reasonably with Mrs C and her family regarding Mr A’s care and treatment.

Redress and Recommendations
The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Mrs C and her family:

We are asking the Board to improve the way they do things:

The Board told us they had already taken action to fix the problem.  We will ask them for evidence that this has happened:

Feedback

Complaints handling:

Given that your complaint was received after 1 April 2017, the Board should have been adhering to the NHS Model Complaints Handling Procedure (CHP).

• on 4 January 2018, the Board said that Mrs C made contact with them by telephone to raise concerns about Mr A’s care and treatment.
• on 23 February 2018, a meeting was held to discuss the concerns.  The Board state the complaint was closed on 26 February 2018 following the meeting.

The meeting was held 36 working days after Mrs C contacted the Board to make the complaint. The CHP states that meetings should be held within 20 working days of receiving the complaint wherever possible. It is not clear from the records available to me why this meeting was not held within 20 working days of the complaint being received.  I have drawn this to the Board’s attention.

Summary

Ms C complained about the care and treatment provided to her late partner (Mr A) by their GP practice (the Practice) prior to his diagnosis of non-small-cell lung cancer stage 3 (advanced cancer).

Mr A had attended the Practice on a number of occasions during a five month period with symptoms of unresolving shoulder pain.  Ms C said Mr A had seen a number of GPs during the period and that a request for a CT scan was refused initially. She also said that the GPs repeatedly prescribed painkillers which were ineffective. When Mr A was finally referred for a CT scan the diagnosis of cancer was made. Ms C felt that the failure of the GPs to refer Mr A for a CT scan had led to a delay in the diagnosis of cancer.

We took independent advice from a general practitioner, which we accepted.

We found that four of the six GPs involved in Mr A's care and treatment had failed to take appropriate action in an effort to determine the cause of Mr A's shoulder pain. Mr A's symptoms had not improved with different types of painkilling medication and after being referred for physiotherapy. A chest X-ray had been taken which was reported as normal. We found that the GPs had failed to consider the complete picture in that Mr A had attended the Practice on numerous occasions within a short timeframe and they dealt with the symptoms reported at the time of the consultations. They had not fully considered the previous consultations which would have allowed them to be better informed of the situation.

We also found that one of the GPs involved had incorrectly advised Mr A that he absolutely did not have cancer, which was an inaccurate statement to have made as at that stage a specialist opinion had not been obtained. This would have given Mr A false reassurance.

We also found that two of the GPs involved in Mr A's care took appropriate action when considering Mr A's reported symptoms and proposed reasonable investigations in an effort to reach a diagnosis.

We upheld Ms C's complaint.

Redress and Recommendations
The Ombudsman's recommendations are set out below:

What we are asking the Practice to do for Ms C:

We are asking the Practice to improve the way they do things:

Feedback

Points to note

As highlighted by the Adviser, the SPSO investigation notes there is evidence of good medical practice by Doctors 1 and 6 in that they took appropriate action when considering Mr A’s reported symptoms and proposed reasonable investigations in an effort to reach a diagnosis.  In reflecting on this complaint, we strongly urge the Practice to share and learn from the positive aspects of the treatment.

Summary

Miss C complained about the care and treatment her late brother (Mr A) received from Tayside NHS Board (the Board).  Mr A had type 1 diabetes with recurrent episodes of hypoglycaemia (when the level of sugar (glucose) in the blood falls below a set point) and a learning disability.  Mr A, who had been a patient with the Board’s diabetes service since he was a teenager, died unexpectedly aged 38 years.

Miss C complained there was a failure by the Board to appropriately assess and treat Mr A and to take account of how his learning disability affected his ability to manage his diabetes care.

We took independent advice from a consultant diabetologist.

Our investigation found that the management of Mr A’s type 1 diabetes, given his learning disability, would have been challenging.  However, in view of Mr A’s recurrent often severe hypoglycaemic episodes and his apparent lack of awareness of his condition and how to manage it effectively, the Board should have focused on the management of his hypoglycaemia, listened to the concerns of Mr A’s family and carried out a full assessment of Mr A’s awareness of hypoglycaemia.  The Board did not provide us with evidence that they did so.

We found that consideration should have been given to investigating whether there were any other possible underlying additional contributing conditions for Mr A’s recurrent hypoglycaemic episodes as recommended in national guidelines and the recognised associations with other autoimmune diseases, given his family history of autoimmune disease. 

While there had been attempts by the Board to change Mr A’s insulin regime in the years prior to his death, which were unsuccessful, there was no evidence that consideration was given to trying other treatment or of a referral to other centres with more expertise in severe hypoglycaemia to try and address and mitigate against Mr A’s recurrent severe hypoglycaemia. 

Although it could not be definitely said that Mr A’s death was as a consequence of a severe hypoglycaemic episode, it was possible given the circumstances of his unexpected death and as recurrent severe hypoglycaemia has been strongly linked as the potential basis for sudden death in persons with type 1 diabetes.

We considered the lack of action by the Board in their management of Mr A’s diabetes represented a serious failure in his care and treatment and we upheld the complaint.

While we acknowledged and welcomed the remedial action the Board has taken on the need to better support people with diabetes and who have a learning disability, we considered this did not go far enough to address the root causes of the issues raised in this case.  In particular, we were of the view the Board had not addressed the underlying clinical issues concerning the assessment and management of patients with type 1 diabetes and recurrent severe hypoglycaemia.  We made a number of recommendations to address the failings in this case.

Redress and Recommendations
The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Miss C:

We are asking the Board to improve the way they do things:

The Board told us they had already taken action to fix the problem.  We will ask them for evidence that this has happened:

Summary

Ms C complained about the care and treatment provided to her late father, Mr A, by Greater Glasgow and Clyde NHS Board (the Board) in the Enhanced Recovery Area at Glasgow Royal Infirmary (the Hospital).  Mr A was admitted to the Hospital with a history of recent weight loss and abdominal pain.  He had a laparotomy (an incision in the abdomen), which showed a lump in his colon.

Mr A underwent a primary anastomosis (where sections of the intestine are reconnected following the removal of diseased tissue).  After the operation, he was admitted to the High Dependency Unit (HDU).  Ms C has stated that the nursing care Mr A received there was excellent and that the family were welcomed to actively participate in his recovery.  She also told us that her father was improving and was mobile in the hours prior to his transfer out of the HDU.  He was then transferred to the Enhanced Recovery Area in the Hospital.  Ms C complained to us about both the medical treatment and the nursing care her father received in the Enhanced Recovery Area when his condition deteriorated.  Following transfer back to HDU, Mr A had further surgery, however, he died there several days later.

We took independent advice from a consultant general surgeon (Adviser 1) and a general nursing adviser (Adviser 2).  In relation to Ms C’s complaint that the Board did not provide reasonable medical treatment to Mr A in the Enhanced Recovery Area, we found that there were a number of failings.  In summary:

• communication with Ms C’s family had been unreasonable and staff had failed to act on their concerns;
• had Mr A been assessed and examined proactively by an experienced doctor earlier, it was likely that they would have recognised his deterioration and escalated his care sooner. Had this happened, there would have been a greater chance of survival;
• a CT scan should also have been carried out sooner and this would have alerted staff to the anastomosis leaking and gross abdominal infection;
• there were case note entries from a variety of junior doctors, but little documented evidence of Consultant involvement;
• there was delay in providing a dietician assessment;
• the majority of medical interventions appeared to be reactive rather than proactive. 

In view of these failings, we upheld Ms C’s complaint that the Board did not provide reasonable medical treatment to Mr A.

Ms C also complained that the Board did not provide reasonable nursing care to Mr A in the Enhanced Recovery Area.  We found that the actions of nursing staff in relation to Mr A’s transfer to the Enhanced Recovery Area had been reasonable.  This included their actions in relation to mobilising Mr A and in maintaining his fluid and nutritional intake.  However, we also found that the monitoring and observation of Mr A had not been reasonable and was not carried out in line with the relevant guidance.  In view of this, we upheld Ms C’s complaint that the Board did not provide reasonable nursing care to Mr A in the Enhanced Recovery Area.

Redress and Recommendations
The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Ms C:

We are asking the Board to improve the way they do things:

Feedback

Points to note

The Board should note Adviser 2’s comment in relation to the entry in the nursing records that the family were, ‘to be encouraged not to visit at mealtimes.’

Complaints handling

The Board are encouraged to reflect on their own handling of the complaint and why their investigation did not identify the good and poor practice in the provision of care.

Summary

Mrs C complained about the care and treatment that staff at Queen Elizabeth University Hospital (the Hospital) provided to her late husband, Mr A.

Mr A previously received hip replacement surgery at the Hospital and was discharged.  He was given clexane on the ward and aspirin on discharge as prophylaxis (preventative medication) to reduce the risk of venous thromboembolism (VTE - blood clots that start in the vein), including pulmonary embolism (a sudden blockage in a major artery).

Approximately three weeks later, Mr A suffered a sudden bleeding from his bowels.  He was re-admitted to the Hospital with a suspected upper-gastrointestinal bleed.  Staff carried out an endoscopy (a procedure to look inside the oesophagus, stomach and first part of the small intestine) and took blood tests.  A sigmoidoscopy (a procedure that involves looking inside the large intestine) could not be carried out.  The next evening, Mr A suffered a sudden collapse and died as a result of a cardiac arrest caused by a pulmonary embolism.

Mrs C raised concerns about the medical and nursing care provided to Mr A, including the investigations carried out, a decision not to give a blood transfusion, monitoring, and the events surrounding his death.

We took independent advice from three clinical specialists: an orthopaedic surgeon, a consultant in acute medicine and a nurse.

As the cause of death was pulmonary embolism, we investigated the VTE prophylaxis given to Mr A during his first admission to the Hospital.  We found VTE prophylaxis in the Hospital was appropriate, but discharge on aspirin was not supported by national guidance and the Board’s own guidelines were not followed.  We noted that there is no completely effective way of preventing pulmonary embolism; however, providing appropriate medication could have reduced the risk to Mr A.  We were unable to rule out the possibility that this failing may have contributed to Mr A’s death.  We also found there was an apparent lack of consultant involvement in Mr A’s pre-operative management.

Our investigation found medical care during the second admission was reasonable.  We noted this was a complex admission, but the correct investigations were carried out and it was appropriate not to give a blood transfusion.  We found medical staff did not miss any warning signs of the pulmonary embolism, noting that pulmonary embolism can occur suddenly, without warning, and with no obvious signs.

We found that nursing care during the second admission was unreasonable.  In particular, there was a failure to record repeat observations for the evening Mr A died.  We also noted, as the Board acknowledged, the difficult circumstances surrounding Mr A’s death could have been handled more sensitively by some staff.

We upheld Mrs C’s complaints and made a number of recommendations to address the issues identified.

Redress and Recommendations
The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Mrs C:

We are asking the Board to improve the way they do things:

The Board told us they had already taken action to fix the problem. We will ask them for evidence that this has happened:

Feedback

Communication

I urge the Board to reflect on how they communicate with families, particularly in sensitive and difficult situations such as the death of loved ones.  In doing so, it would be appropriate to consider what use is made of resources such as death and dying teaching and written resources such as the Scottish Government’s publication ‘What to do after a death’, to support the families of patients at such difficult times.

Summary

Ms C complained on behalf of her nephew (Mr A) about the care and treatment Mr A received from the Greater Glasgow and Clyde NHS Board (Board 1).  Ms C’s complaint concerned the delays in treatment for Mr A’s dural arteriovenous fistula (DAVF – where there are rarer, abnormal connections between arteries and veins in a protective membrane on the outer layer of the brain and spine, called the dura. Symptoms can include an unusual ringing or humming in the ears, particularly when the DAVF is near the ear, and some patients can hear a pulsating noise caused by the blood flow through the fistula) and the poor communication with him about this.  The original complaint we received concerned the treatment of Mr A’s arteriovenous malformation in the brain (AVM - where a tangle of blood vessels in the brain or on its surface bypasses normal brain tissue and directly diverts blood from the arteries to the veins). During the course of our investigation, it was identified that there were different types of AVM and that Mr A had one type, known as DAVF.

We obtained independent advice on the case from a consultant neurosurgeon, a consultant interventional neuroradiologist and a consultant in public health medicine.

We found that that Board 1 unreasonably failed to provide Mr A with treatment for his DAVF and we upheld this part of the complaint. We also found that, having advised Mr A that a hospital in another board’s area was willing to provide treatment for his condition, Board 1 then failed to make arrangements for this within a reasonable time and we upheld this part of the complaint. We found that Board 1 failed to keep Mr A updated on his proposed treatment and that Mr A and his family had to contact Board 1 repeatedly to find out what was happening and that Board 1 also failed to respond to Mr A’s email detailing his concerns about Board 1’s response to his complaint. We, therefore, upheld this part of the complaint. We made a number of recommendations to address the failings in this case.

Redress and Recommendations
The Ombudsman's recommendations are set out below:

What we are asking Board 1 to do for Ms C and Mr A:

We are asking Board 1 to improve the way they do things:

Feedback

Response to SPSO investigation

Board 1 failed to respond to my enquiries by the deadlines set and failed to provide full and complete responses, which delayed our investigation of Ms C’s complaint.

Summary

Mrs C complained to me about the care and treatment she received from Lanarkshire NHS Board (the Board).   Her concerns relate to the treatment she received following her operation to form a stoma (an opening in the stomach to divert bodily waste through so it can be collected in a bag).

Mrs C was admitted to Monklands Hospital (the Hospital) on a number of occasions after this operation, with on-going symptoms of nausea and stomach pain.   In the last admission, Mrs C's small bowel perforated (a hole formed in it) and she developed sepsis (a severe complication of infection).   Mrs C received emergency surgery from which she recovered, however, she developed neurological problems which have left her partially sighted and with a weakness down her left side.   Mrs C raised concerns that there was a delay in recognising the seriousness of her condition and in performing surgery to treat it.   Mrs C felt that if earlier action had been taken, she might not have developed these neurological problems.

We took independent advice from a general and colorectal surgeon, which we accepted.

We found that Mrs C had an incomplete small bowel obstruction (blockage) where the stoma was formed, caused by tissue swelling.   We found that Mrs C's symptoms, her repeated admissions to the Hospital and the results of the investigations carried out were all suggestive of this.   We considered it was unreasonable that the Board did not recognise this at the time.   We also considered it was unreasonable Mrs C was not referred for surgery at an earlier point, particularly when her condition worsened.   We concluded that if surgery had been carried out earlier, Mrs C would probably not have developed severe sepsis, which is the likely cause of her neurological problems.   We were concerned that the Board's review did not identify any failings in the care provided to Mrs C.

We upheld Mrs C's complaint.   We made a number of recommendations to address the issues identified.   The Board have accepted the recommendations and will act on them accordingly.   We will follow-up on these recommendations.   The Board are asked to inform us of the steps that have been taken to implement these recommendations by the date specified.   We will expect evidence (including supporting documentation) that appropriate action has been taken before we can confirm that the recommendations have been implemented.

Redress and Recommendations
The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Mrs C:

We are asking the Board to improve the way they do things:

Summary

Mr C complained about orthodontic treatment he received over a number of years to address crowding in both his upper and lower jaws.   After he lost one of his upper front teeth due to an injury and infection, the decision was taken to move the remaining upper front tooth across the centre of his mouth to fill the gap, whilst also moving the other teeth to resolve the crowding issues.

Mr C was initially told that the treatment was expected to take between 18 and 24 months.   However, after around two and a half years of treatment, his original orthodontist left the practice.   The subsequent orthodontist was concerned about the appropriateness of the treatment plan and referred Mr C to an orthodontic consultant after identifying a deterioration of Mr C's bone structure and tooth roots.   The decision was taken to cease treatment due to the risk of further damage.   Mr C was left with the tooth in the centre of his mouth.   A veneer was then required to make the tooth appear more normal.

We took independent advice from an orthodontics adviser on the treatment that Mr C received from the initial orthodontist.   The adviser considered the treatment plan was unusual.   As such, the adviser would have expected there to be evidence of discussions with restorative dentists, because restorative work would be required after orthodontic treatment was complete in order to make the moved teeth appear normal.   However, this did not take place.

The adviser was also critical of the quality of the records, which were unreasonably abbreviated and lacked evidence that alternative treatment options were discussed with Mr C, potentially making the consent he gave for the treatment plan invalid.   The notes also failed to confirm whether a previously identified infection had resolved before orthodontic treatment was commenced, meaning this could not be ruled out as a factor in the bone structure and tooth deterioration Mr C experienced.

For these reasons, we considered that the treatment fell below a reasonable standard and we upheld the complaint.

Further to the clinical failures, we also identified concerns with the orthodontist's complaints handling and communication, both with Mr C and the SPSO.   Throughout the complaints process, the orthodontist missed 11 deadlines for response, sometimes by a number of weeks or months and often without contact to explain the delay.   The orthodontist also failed to provide all of the information requested on a number of occasions.

Redress and Recommendations
The Ombudsman's recommendations are set out below:

What we are asking the Orthodontist to do for Mr C:

We are asking the Orthodontist to improve the way they do things: