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Health

  • Report no:
    201701715
  • Date:
    May 2018
  • Body:
    Dumfries and Galloway NHS Board
  • Sector:
    Health

Summary

Mr C complained about the care and treatment provided to him by the board after he was diagnosed with prostate cancer.  His prostate cancer was considered low risk and the plan was for active surveillance, which involves having a PSA test (prostate specific antigen: a marker in blood tests which can indicate prostate problems) three to four times a year, and an MRI scan six months after diagnosis.  However, Mr C complained that he was not given a PSA test until nearly a year after his diagnosis, and the MRI scan was not organised in a timely manner. 

We took independent, professional advice from a urologist.  We found that the board failed to:

  • arrange follow-up appointments;
  • arrange PSA tests that required to be undertaken;
  • check that PSA tests were undertaken as intended;
  • make adequate and timely arrangements for an MRI scan which took
    Mr C’s special needs into account; and
  • provide Mr C with information that might have enabled him to make alternative arrangements to get the necessary tests done.

Given these failings, we upheld this aspect of Mr C's complaint. 

Mr C also complained that the board failed to communicate appropriately with him regarding the monitoring of his prostate cancer.  We found that when Mr C was diagnosed the need for regular PSA testing and the MRI scan were not communicated to him or his GP appropriately.  We also found that when Mr C was contacted regarding the MRI scan, the information he was given did not answer all of his questions, nor was he fully informed of his options.  We upheld this aspect of Mr C's complaint.

Finally, Mr C complained about the board's handling of his complaint.  We found that Mr C's complaint to the board had been incorrectly logged as a concern rather than a complaint.  We also found that communication with Mr C throughout and after the complaints process had been poor.  We upheld this aspect of Mr C's complaint. 

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

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

Complaint number

What we found

What the organisation should do

Evidence SPSO needs to check that this has happened and the deadline

(a), (b), & (c)

 The Board failed to provide appropriate monitoring following a diagnosis of prostate cancer; failed to communicate appropriately; and handled Mr C’s complaint unreasonably

Apologise to Mr C for failing to provide appropriate monitoring following a diagnosis of prostate cancer; failing to communicate appropriately; and handling his complaint unreasonably

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance

Copy or record of apology

By:  20 June 2018

 

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

Complaint number

What we found

What should change

Evidence SPSO needs to check that this has happened and deadline

(a)

 The Board failed to provide appropriate monitoring following a diagnosis of prostate cancer Prostate cancer patients on active surveillance should be properly and appropriately monitored

Evidence of a review of current systems to monitor prostate cancer patients on active surveillance, which includes an assessment of the reliability and effectiveness of these systems and any improvements to be made as a result of the review

Evidence that there has been a review of all prostate cancer patients on active surveillance to ensure they are being actively followed up

By:  15 August 2018
(a) There was a failure to make adequate and timely arrangements for a scan which took Mr C’s needs into account There should be a system in place to accommodate patients with special needs such as claustrophobia who are required to undergo scanning

Evidence that a system has been put in place to make arrangements for patients with special needs such as claustrophobia to undergo scanning and that this system has been communicated to all the relevant staff

By: 15 August 2018
(b) When Mr C was diagnosed with prostate cancer it was not communicated to him that he would need three monthly testing and scanning after six months Patients on active surveillance for prostate cancer should have the follow-up requirements clearly explained to them

Evidence that this has been considered and a system is in place to ensure that patients on active surveillance for prostate cancer have the follow-up requirements clearly explained to them

By: 15 August 2018
(b) When Mr C was contacted regarding scanning, the information he was given did not answer his questions, nor was he fully informed of his options Clear information should be given regarding options for scanning, and staff should make efforts to ensure they are answering all of a patient's questions 

Evidence that this has been fed back to the relevant staff in a supportive way that encourages learning 

By: 4 July 2018
(c)

Mr C’s complaint was handled unreasonably

 Complaints should be accurately logged and responded to in line with the complaints handling process

Evidence that this has been fed back to the relevant staff in a supportive way that encourages learning 

 

By: 4 July 2018
(c) Communication with Mr C during and after the complaint process was poor Communication with complainants should be pro-active, and complainants' requests for contact should be returned

Evidence of a review of the communication during and after the complaints process in this case, including an assessment of why staff failed to return Mr C's requests for contact and what action will be taken to avoid this recurring in the future 

By: 15 August 2018

 

Feedback
Points to note
The Board could consider raising awareness of their clinical staff about the current options of Healthcare in Europe for patients. 

Related reading

  • Report no:
    201700591
  • Date:
    May 2018
  • Body:
    Grampian NHS Board
  • Sector:
    Health

Summary

Ms C complained about the care and treatment she received when she presented to the Neurology Department (the Department) at Aberdeen Royal Infirmary following a referral from an out-of-hours GP.  Two days following her first presentation to the Department, Ms C was diagnosed with cauda equina syndrome (a rare and serious neurological condition that affects the bundle of nerves (cauda equina) at the base of the spine).  Ms C raised concern that there had been a delay in carrying out an MRI scan and, following this, performing surgery for her condition.  Ms C felt that if her condition had been diagnosed and treated sooner, her chance of making a more complete recovery would have increased.

We took independent advice from a consultant neurosurgeon, which we accepted.

We found that there was an unreasonable delay in providing Ms C with appropriate treatment.  We noted that, under the clinical guidance in place at the time, the Board should have carried out an emergency MRI scan and then performed emergency surgery during Ms C's first admission.  We considered that it was unreasonable that Ms C did not receive an MRI scan and surgery until she returned to the Department two days later.  We concluded that, if the surgery had been carried out when it should have been, then it is more likely that Ms C would have maintained better urological and sexual function.  However, we were unable to say that Ms C would have recovered to normal function.  We also found failings with the documentation of the assessments carried out in the Department during both admissions and we were unable to conclude that the assessments were reasonable.

Ms C was also dissatisfied with the Board's response to her complaint.  We found that the Board's response had referred to a timescale for providing surgery that was not relevant in this case.  We considered that the Board should have considered their response more carefully and referred to relevant guidelines.  We considered that the Board failed to establish all of the facts relevant to the points Ms C raised.  We concluded that the Board's response to Ms C's complaint was unreasonable. 

We upheld Ms C's two complaints and made a number of recommendations to address the issues identified. The Board have accepted these recommendations and 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 dates specified. We will expect evidence (including supporting documentation) that appropriate action has been taken before we can confirm 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 Ms C:

Complaint number

What we found

What the organisation should do

Evidence SPSO needs to check that this has happened and the deadline

(a) and (b)

There was an unreasonable delay in performing an MRI scan and carrying out surgical treatment on Ms C

There was a failure to adequately document Ms C's medical assessments on 14 and 16 June 2017

The Board's response to Ms C's complaint failed to establish all of the facts relevant to the points Ms C raised and was unreasonable

Apologise to Ms C for the unreasonable delay in providing her with treatment and the impact this has had upon her, the failure to adequately document medical assessments and for failing to respond to her complaint reasonably.

The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance

A copy or record of the apology

By:  20 June 2018

 

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

Complaint number

What we found

What should change

Evidence SPSO needs to check that this has happened and deadline

(a)

 There was an unreasonable delay in performing an MRI scan and carrying out surgical treatment on Ms C

Neurology, Neurosurgery, Neuroradiology staff should be aware of current pathways and guidelines for the management of patients with cauda equina syndrome

Patients with suspected cauda equina syndrome should receive an emergency MRI scan

Evidence that the cauda equina pathway and guidance in place has been shared with staff who assess and investigate emergency neurosurgery admissions

Evidence that the Board, when assessing the proposal to increase access to weekend MRI scanning, have taken into account the recognised standards in place for access to emergency MRI.  The Board should provide me with reasons for their decision to take action (or not do so) in relation to this matter

By:  15 August 2018

(a)

 There was no documentation of the neurological assessments carried out on 14 and 16 January 2017, nor the discussion between the Registrar and the Neurosurgeon

Assessments of patients, referral conversations and conclusions should be fully documented in their medical records

Evidence that SPSO's findings on this complaint have been fed back in a supportive manner to the staff involved in Ms C's care and that they have reflected on the Adviser's comments. (For instance, a copy of a meeting note or summary of a discussion)

By:  20 June 2018

(b)

 The Board failed to establish all of the facts relevant to the points Ms C raised and it was not apparent that relevant standards and guidance were considered In line with the NHS Scotland Complaints Handling Procedure, complaints investigation should establish all the facts relevant to the points made in the complaint and give the person making the complaint a full, objective and proportionate response that represents the Board's final position

Evidence that SPSO's findings on this complaint have been fed back in a supportive manner to the staff involved in investigating and handling Ms C's complaint.  (For instance, a copy of a meeting note or summary of a discussion)

By:  20 June 2018

 

Feedback
Response to SPSO investigation
The Board should ensure that all relevant evidence is provided to my office when this is first requested.  In this case, the Board's failure to do this contributed to delays in the investigation.

Points to note on best practice
In view of the record-keeping and complaints handling issues identified, the Board should consider sharing this report more widely with staff in other services to highlight the importance of these matters.

Related reading

  • Report no:
    201607746
  • Date:
    April 2018
  • Body:
    Lanarkshire NHS Board
  • Sector:
    Health

Summary

Mrs C, who works for an advice and support agency, complained on behalf of Mrs B about the care and treatment provided to Mrs B's late father (Mr A) by Lanarkshire NHS Board at Hairmyres Hospital (the hospital).  Mr A had diabetes and had been admitted to the hospital to have his leg amputated.  Mrs C complained that his diabetes was not properly monitored or managed following the surgery.  She said that this led to the development of diabetic ketoacidosis (DKA - a serious problem that can occur in people with diabetes if their body starts to run out of insulin).  She also complained about the actions of nursing staff.

We took independent advice from three advisers:  a consultant in acute medicine, a diabetes specialist nurse and a general nursing adviser.  In relation to Mrs C's complaint that the Board did not provide reasonable treatment to Mr A, we found that there were a number of serious failings, which were that the board failed to:

  1. adequately monitor Mr A's blood glucose and respond to both hypo-glycaemia (low blood sugars) and hyper-glycaemia (this occurs when people with diabetes have too much sugar in their bloodstream);
  2. manage Mr A's diabetes and insulin administration in line with the board's protocol;
  3. recognise and respond in a timely manner to his deterioration; and
  4. recognise the possibility of heart problems whilst he was in the medical High Dependency Unit (HDU).

The advice we received also highlighted a number of other failings:

  1. When Mr A was transferred to the medical HDU overnight, he was not seen until the following morning.  This was an unreasonable delay given the severity of his illness and the complexities of managing DKA in a patient with known cardiac problems (aortic stenosis – tightening of one of the valves in the heart and impairment of the heart as a muscle).  This would have made providing the large quantities of fluid as part of DKA management potentially difficult.
  2. Mr A was transferred out of medical HDU despite signs that he was starting to deteriorate.  There was then a delay in reviewing him when he was transferred back to the surgical ward.  We found that Mr A should have subsequently been readmitted to medical HDU or to coronary care.
  3. Mr A should have had a review of his antibiotics during his second deterioration, as he had already been on his antibiotic regime for three days and would have probably needed different antibiotics and review of any microbiology results.
  4. There was a failure to measure/chart his respiratory rate when he was deteriorating.

     

In view of these failings, we upheld Mrs C's complaint that the board did not provide reasonable treatment to Mr A.

Mrs C also complained that the board did not provide reasonable nursing care to Mr A in the hospital.  She said that nursing staff did not respond reasonably to alerts from another patient's visitors about Mr A's condition and that nursing staff did not reasonably record the actions they took in relation to this in Mr A's medical notes.

We found that the actions of a nurse when Mr A's condition deteriorated had been unacceptable and unreasonable.  The nursing documentation in relation to this matter was also inadequate and we upheld this aspect of Mrs C's complaint.

Finally, Mrs C complained that the board did not respond reasonably to Mrs B when she complained to them about these issues.  We upheld this aspect of the complaint, as the board failed to identify the serious failings referred to above.  We considered that this was both unreasonable and that it called into question the adequacy of the board's complaints handling at the time.

Redress and Recommendations

The Ombudsman's recommendations are set out below:

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

Complaint number

What we found

What the organisation should do

Evidence SPSO needs to check that this has happened and the deadline

(a) and  (b)

The Board did not provide Mr A with reasonable treatment.

The nursing documentation in relation to the actions of the nurse when Mr A's condition deteriorated on 4 October 2016 was inadequate

Apologise to Mrs B for failing to provide Mr A with reasonable treatment and for the inadequate nursing documentation.  The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance

A copy or record of the apology.

 

By:  25 May 2018

 

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

Complaint number

What we found

What should change

Evidence SPSO needs to check that this has happened and deadline

(a)

The Board failed to adequately monitor Mr A's blood glucose and respond to both hypo- and hyper-glycaemia

The Board should reflect on the findings in this report and ensure patients with erratic blood glucose have their capillary blood glucose checked and recorded regularly and at a frequency appropriate to their specific circumstances and condition

Evidence that relevant staff have been informed of this and that consideration has been given to any training requirements to support staff in carrying out these checks.

 

By:  25 July 2018

(a)

The Board failed to manage Mr A's diabetes and insulin administration

Nursing and medical/surgical staff should be competent, appropriately skilled, and able to access guidance, support and training in relation to diabetes management in hospital, including recognising diabetic emergencies and advice on who they can contact if they have concerns, including at the weekend

Evidence that staff have the appropriate level of skill and access to guidance, support and training.

 

By:  25 July 2018

(a)

There was a delay in reviewing Mr A when he was transferred to the medical HDU

Admissions to the medical HDU should be seen on arrival by medical staff

Evidence this matter has been considered and a decision taken to act (or not), that includes reasons for the decision.

 

By:  25 June 2018

(a)

Staff failed to recognise the possibility that Mr A had heart problems in medical HDU on 5 October 2016

Medical HDU should ensure that electrocardiograms are routinely and appropriately reviewed for patients who have deteriorated or been admitted overnight

Evidence that this matter has been considered and, where appropriate, action has been taken and any changes disseminated.

 

By:  25 June 2018

(a)

Mr A was transferred out of the medical HDU on 6 October 2016, despite signs that he was starting to deteriorate

Patients who are deteriorating should not be discharged from the medical HDU without a clear plan

Evidence that this matter has been fed back to staff in a supportive way that encourages learning.

 

By:  25 June 2018

(a)

There was a delay in recognising and starting treatment for possible sepsis

Nursing and medical/surgical staff should be competent, appropriately skilled, and able to access guidance, support and training in relation to the consideration of sepsis and on reviewing antibiotics previously prescribed

Evidence that staff have the appropriate level of skill and access to guidance, support and training.

 

By:  25 July 2018

 

 

(a)

There was a delay in reviewing Mr A when he was transferred back to the surgical ward in the late afternoon of 6 October 2016

Patients who have been transferred out of a HDU environment to a general ward should be reviewed on arrival in the ward or as close to that time as possible

Evidence that this matter has been considered and a decision taken to act (or not), that includes reasons for the decision.

 

By:  25 June 2018

(a)

There was a failure to measure/chart Mr A's respiratory rate

Nursing and medical/surgical staff should be competent, appropriately skilled, and able to access guidance, support and training in relation to early warning scores with regard to the importance of respiratory rate

Evidence that staff have the appropriate level of skill and access to guidance, support and training.

 

By:  25 July 2018

(c)

The Board's investigation into Mrs B's complaint failed to identify a large number of the failings we have referred to in this report

The Board should reflect on the findings in this report and ensure that complaints are investigated appropriately

Evidence that relevant staff have been informed of this and that consideration has been given to any training requirements to support staff in investigating complaints.

 

By:  25 July 2018

 

Related reading

  • Report no:
    201602341
  • Date:
    February 2018
  • Body:
    Fife NHS Board
  • Sector:
    Health

Summary
Mrs C complained about the care and treatment provided to her late husband (Mr C) by Fife NHS Board (the board).  Mrs C's complaint related to delay in diagnosing that Mr C had lung cancer and the treatment provided to Mr C.  Mrs C complained that the standard of care Mr C had received had been poor.

We took independent advice from a consultant respiratory physician.  We found that Mr C was high risk for lung cancer, given his history as a former smoker with a background of heavy exposure to asbestos, and presenting with a cough and breathlessness.  There were also concerning features in Mr C's radiology results and his case was complex.  Despite this, Mr C was removed from an expedited cancer referral pathway without his case being discussed at a lung cancer multi-disciplinary team (MDT) meeting and without consideration given to a tissue biopsy being carried out.  There was also no evidence that there had been any discussion with Mr C to enable him to make an informed decision about his future treatment.  We also considered that that the board did not appear to have followed national standards and guidelines in Mr C's case.

The advice we received was that this represented serious failings in Mr C's care and treatment and that if such action had been taken, this could potentially have resulted in a different outcome for Mr C.  As such, we upheld this complaint.  The board have told us they now have systems and processes for patients in a similar situation to Mr C which they say are significantly different from what was previously in place and are willing to have their lung cancer service independently audited and peer reviewed.  In view of the failings we identified, we made a number of recommendations to address this.

Mrs C also complained about the palliative nursing care Mr C received following his cancer diagnosis.  We took independent nursing advice.  We found that although the board had taken action following Mrs C's complaint, the advice we received was that there were serious failings in the nursing care provided to Mr C following his cancer diagnosis which had not been identified or addressed by the board.  There had been a failure to comply with professional and clinical standards for practice which would be expected of the nursing staff and the palliative care provided had fallen below the standards which Mr C and his family should have reasonably expected.  We upheld this complaint and made a number of recommendations to address the issues identified.

Mrs C also complained that the board's handling of her complaint was inadequate.  We were satisfied there were failings in how the board responded to Mrs C's complaint and upheld this part of her complaint.  We made recommendations to address these failings.

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

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

Complaint number

What we found

What the organisation should do

Evidence SPSO needs to check that this has happened and the deadline

(a), (b), (c)

There were serious failings in diagnosing that Mr C had lung cancer and in the treatment he received.

There were serious failings in the nursing care provided to Mr C after his cancer diagnosis in June 2015.

There were failings in the Board's handling of Mrs C's complaint

Apologise to Mrs C for the failings in:  Mr C's diagnosis and treatment; the nursing care provided to Mr C after his cancer diagnosis in June 2015; and the handling of Mrs C's complaint.

The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance

A copy or record of the apology

By:  21 March 2018

 

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

Complaint number

What we found

What should change

Evidence SPSO needs to check that this has happened and deadline

(a)

Mr C was unreasonably removed from the expedited lung cancer referral pathway without his case being discussed at a lung MDT meeting, which led to a delay in diagnosing that he had lung cancer.  This adversely impacted on Mr C's outcome

Patients who present with suspected lung cancer symptoms should not be removed from the expedited lung cancer referral pathway without the case being discussed at a lung MDT meeting

A copy of the current systems and processes in place on the removal of patients from the cancer referral pathway showing they take into account national guidance and the appropriate process for discussion at a lung MDT meeting.

Evidence of the review of patients who were removed from the referral pathway in the same year as Mr C.

Evidence that the Board has carried out an independent and impartial review of the lung cancer service which includes considering the appropriateness of any decision to remove a patient from the lung cancer care pathway without an MDT meeting being held.  The evidence is to include providing SPSO with a briefing document outlining the scope of the review; who will be carrying out the review; and a report on the outcome of the review.

Evidence that this report has been shared with relevant staff and managers in a supportive way for reflection and learning

By:  21 August 2018

(a)

There was a failure to involve Mr C in making an informed decision about his treatment

Patients should be fully informed and involved in decisions about their treatment

Evidence that this report has been shared with relevant staff and managers in a supportive way for reflection and learning

By:  23 April 2018

(a)

There was a failure to refer Mr C to a lung MDT meeting when cancer was diagnosed and it became apparent that the skin lesion was metastatic

Patients should be appropriately referred to a MDT meeting.

Evidence that patients are being appropriately referred for discussion at MDT meetings within the lung cancer service (this could be evidence provided as part of the audit referred to above)

By: 23 April 2018

(b)

Mr C and his family did not receive the standard of palliative nursing care and support which they should have reasonably expected to receive

Patients who require palliative nursing care and their families should the receive care and support needed.  This should be adequately led, co-ordinated and person-centred

Details of a review of the Palliative Care Service with evidence that any training needs identified as part of the review are being met, or planned (with definitive timescales, not simply a broad intention).

Evidence that this report has been shared with relevant staff and managers in a supportive way and that reflection and learning have taken place

By:  23 April 2018

(b)

There was a failure by nursing staff to comply with national guidance and standards; in particular, in relation to assessing and managing pain and distress; and maintaining care plans

Nursing staff should ensure that national guidance and standards are adhered to; in particular, in relation to the assessment of pain and distress and managing care plans

Evidence that this report has been shared with relevant staff and managers in a supportive way for reflection and learning

By:  23 April 2018

(b)

There was a failure to comply with NMC and Scottish Government requirements for prescribing

The Board should ensure that systems are in place to ensure that nurse prescribing complies with NMC standards and Scottish Government guidance

Details of the system in place (including procedures or instructions to staff) to ensure the safe prescribing of medicine by all non-medical prescribers which follows NMC and Scottish Government standards and guidance

Evidence that the Board have reviewed whether relevant nursing staff have received sufficient training in the prescribing of medication, particularly to address the failings identified in this report and evidence of how training will be kept up to date

By:  23 April 2018
(b) There were omissions in record-keeping in relation to the recording of nursing care provided to Mr C Nursing records should be maintained in accordance with the nursing and midwifery code of practice and standards

Evidence that the findings of this report have been shared with relevant staff and managers in a supportive way, and what action has been taken as a result.

By:  23 April 2018
(c) The Board's handling of Mrs C's complaint fell below a reasonable standard Staff should be aware of the importance of keeping complainants updated and providing a full response

Evidence that the model CHP has been circulated with attention drawn to matters of particular relevance

By: 23 April 2018

 

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

Complaint number

What we found

What the organisation say they have done

Evidence SPSO needs to check that this has happened and deadline

(c)

The Board acknowledged that documents relating to a meeting about Mr C's case had not been located during the Board's investigation of Mrs C's complaint

The Board had raised what had occurred with the department responsible and taken action to address how they stored health records; and they were also introducing a new electronic system during 2017 which will provide a single point for all patient information to be logged electronically

Evidence, such as: discussions about what occurred; the changes that have been made; and revised procedures or instructions to staff about the storage of patient information records

By:  23 April 2018

 

Related reading

  • Report no:
    201608430
  • Date:
    January 2018
  • Body:
    Greater Glasgow and Clyde NHS Board
  • Sector:
    Health

Summary
Mrs C complained about the care and treatment she received from Queen Elizabeth University Hospital Glasgow (the hospital).  Mrs C was concerned about delays in the time taken for her to receive spinal surgery to address her medical condition (incomplete cauda equina syndrome).  In addition, Mrs C complained about the level of care provided during her two admissions by physiotherapy and nursing staff.  Mrs C also raised concerns about the aftercare arrangements made at the time of her discharge from the hospital.

We took independent advice from three clinical specialists:  a consultant neurosurgeon, a physiotherapist and a nurse.

We found that the board failed to provide neurosurgery to Mrs C within a reasonable time.  We noted that there had been unexpected repair works at the hospital that impacted on theatre availability; however, there is clear guidance on the need for surgery to be performed on an emergency basis in cases of incomplete cauda equina syndrome to minimise the risks associated with this condition.  In these circumstances, we considered it was unreasonable for the board not to have provided the surgery, or arranged for this to take place at an alternative hospital site.  We considered that it was likely that the delay would have impacted on Mrs C's poor outcome following the surgery.  Our investigation also highlighted that there was no evidence of communication with Mrs C about the risks of the delays while she was on the neurosurgery ward, and that documentation in the relevant medical records was of a very poor standard.

Our investigation identified failings in the care and treatment provided to Mrs C during her admissions.  We found that Mrs C's care while in hospital and on discharge did not appear to have been planned in a co-ordinated and multi-disciplinary way.  We found that Mrs C did not receive an adequate level of physiotherapy care.  We also had concerns about the level of continence care provided to Mrs C, the management of her pain and wound care based on the evidence in the nursing records.

We found that there were failings in discharge planning and aftercare arrangements for Mrs C.  We considered this was not planned in a co-ordinated and multi-disciplinary way.  Our investigation also found there was inadequate patient information provided to Mrs C on discharge, and referrals for aftercare were not made.  We noted that this likely contributed to Mrs C's difficult and distressing experience returning to her home.

We upheld Mrs C's three complaints and made a number of recommendations to address the issues identified.  The board have accepted these recommendations and 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 dates specified.  We will expect evidence (including supporting documentation) that appropriate action has been taken before we can confirm 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:

Complaint number

What we found

What the organisation should do

Evidence SPSO needs to check that this has happened and the deadline

(a), (b) and (c)

There was an unreasonable delay in providing neurosurgery to Mrs C.  There were also failings in the physiotherapy and nursing care offered to Mrs C and failings in the multi-disciplinary and discharge planning processes

Apologise to Mrs C for the delay in providing neurosurgery; the failings in physiotherapy and nursing care and in the multi-disciplinary and discharge planning processes.

The apology should meet the standards set out in the SPSO guidelines on apology available at: https://www.spso.org.uk/leaflets-and-guidance

A copy or record of the apology

By:  24 February 2018

 

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

Complaint number

What we found

What should change

Evidence SPSO needs to check that this has happened and deadline

(a)

There was an unreasonable delay in providing surgery to Mrs C, who was suffering incomplete cauda equina syndrome

Surgery for cauda equina should be performed within recommended timescales (in this case 24 to 48 hours), or the patient considered for transfer to an alternative hospital site

The Board should demonstrate that they have systems in place to ensure patients with incomplete cauda equina are operated on as an emergency, or transferred to an alternative hospital site for surgery

By:  24 April 2018

(a) and (b)

There were significant failings in record-keeping.  The ward review documentation was very poor in this case.  There were gaps in nursing records (including assessments and fluid balance charts)

The Board should ensure staff complete adequate and contemporaneous medical documentation

The Board should demonstrate how this issue has been raised with relevant staff in a supportive way for reflection and learning and that learning has taken place and/ or relevant future training and development identified

By:  24 April 2018

(a), (b) and (c)

There were unacceptable failings in communication.  There is no evidence that information was given about the risks of delays to the surgery.  Mrs C was not given an appropriate level of information on discharge

Patients should receive relevant and understandable information about cauda equina syndrome

The Board should demonstrate how they will provide patients presenting with cauda equina syndrome with such information and in what way:  for example, through discussions and an information leaflet

By:  24 April 2018

(b)

There were failings in the physiotherapy care.  Despite the record of Mrs C's anxiety, only one pre-discharge supervised trial of stairs was undertaken by physiotherapy

The Board should ensure an adequate level of physiotherapy assistance for patients in Mrs C's position

The steps the Board will take to ensure adequate physiotherapy support is provided to patients following surgery for cauda equina syndrome.

By:  24 April 2018

(b)

Mrs C's nursing assessment, both on admission to and during her stay in hospital, did not include sufficient detail on her symptoms of both pain and incontinence and wound management. Neither did it include the psychosocial impact of her diagnosis and symptoms on her health

Registered nurses should have the knowledge to carry out comprehensive assessments and to develop clear care plans which facilitate consistent and person-centred care.

The Board should ensure that registered nurses can assess the psychosocial impact of illness for patients admitted to hospital and can plan care to ameliorate its effects as much as possible

The Board should demonstrate that they have:

  • reviewed their approach to both incontinence and pain management in in-patient settings;
  • that learning has taken place; and
  • put in place steps to implement any actions identified within definitive timescales

By:  24 April 2018

(b) and (c)

 Mrs C's care while in hospital and on discharge does not appear to have been planned in a co-ordinated and multi-disciplinary way.  Her nursing and physiotherapy records have little evidence of input from other professionals.  The records did not suggest Mrs C was involved in discharge planning, or her perception of needs or anxieties considered

A supportive multi-disciplinary approach should be in place for patients with cauda equina syndrome

The Board should demonstrate they have reviewed their approach to multi-disciplinary working in in-patient settings to ensure that care is person centred and co-ordinated to optimise recovery for patients while in hospital.  Consideration should be given to the use of multi-disciplinary records which facilitate better person-centred assessment and care planning

By:  24 April 2018
(c) There were failings in the discharge planning and arrangements made for Mrs C Discharge should be planned in a co-ordinated way.  A personalised aftercare plan should be undertaken prior to discharge in cases of this type and include prompt referral to appropriate services.  The Board should ensure that patients returning home from hospital have the appropriate referrals made to community based services to support their care on discharge from hospital.  This should include the transfer of care plans with the patient, where appropriate, to ensure continuity and consistency of care

An explanation with supporting documentation of the steps the Board will take to ensure appropriate discharge planning

By:  24 April 2018

 

Feedback
Complaints handling
I agree with Adviser 3's comment about the Board's handling of this complaint.  The Board did not investigate this complaint in a sufficiently detailed and analytical manner.  They appeared defensive of, and failed to take account of the gaps in, nursing practice as evidenced in the nursing notes.  While printed nursing records are lengthy, and consideration has been given to how they might facilitate assessment and care planning, it was nonetheless difficult (on the basis of this investigation) to understand the priorities for Mrs C's care. This must cause difficulty in personalising the care to meet individual patient need and for nurses, working different shifts, to be clear about the care plan.

Points to note on best practice
In line with the views of Adviser 2, I would ask the Board to consider the following points about delivering best practice in the care of patients presenting with cauda equina syndrome:

  • patient representation on the Cauda Equina Forum;
  • patient information developed for people who are at risk of developing cauda equina syndrome and for those with incomplete cauda equina syndrome for issue at the time of diagnosis;
  • to ensure that the diagnosis of cauda equina syndrome is recorded, explained to the patient and communicated clearly across the multi-disciplinary team;
  • training arranged for all members of the clinical team to ensure that; the diagnosis of cauda equina syndrome, the prognosis and the importance of personalised co-ordinated postoperative management are understood;
  • a clear pathway to urology;
  • a clear pathway to pain services; and
  • a governance reporting system for cases who have poor post-operative outcomes related to cauda equina syndrome.

Points to note on the development of the information leaflet
The Board is asked to consider the following suggestions from Adviser 2 for further improvement:

  • page 2:  It is important to treat cauda equina syndrome as an emergency not urgently;
  • page 3:  the symptoms of cauda equina syndrome can also occur gradually, often related to spinal stenosis;
  • page 4:  women may also have sexual dysfunction related to vaginal numbness;
  • page 7:  links to patient support groups such as; www.caudaequina.org,  www.ihavecaudaequina.com or www.caudaequinauk.com might be included; and
  • the inclusion of guidance on when and where to seek help should symptoms deteriorate.

 

Related reading

  • Report no:
    201607558
  • Date:
    December 2017
  • Body:
    Lanarkshire NHS Board
  • Sector:
    Health

Summary
Mr C complained about the care and treatment his late wife (Mrs C) received from the Emergency Department at Monklands Hospital (the hospital) when she attended with abdominal pain.  Mr C was concerned that Mrs C had been discharged home during the early hours of the morning without being assessed properly and that she was in pain.

We took independent advice from two clinical specialists, including a consultant in emergency medicine and a consultant in emergency general surgery.  We considered that the clinical assessments and record-keeping by two different doctors who reviewed Mrs C fell below a reasonable standard.  In addition, we found that there was no evidence to demonstrate that Mrs C had been offered pain relief despite it having been documented that she was experiencing moderate to severe pain.

We also found that a significantly abnormal blood test result had been overlooked by the board on three separate occasions:  at the time Mrs C was discharged from hospital; when providing clinical information to the Crown Office and Procurator Fiscal Service's forensic pathologist; and when investigating Mr C's complaint.  We considered that, had a more senior doctor overseen Mrs C's care, and due attention been given to this test result, she would have been admitted to hospital which may have avoided her death.

In terms of Mrs C being discharged home during the early hours of the morning, we considered this unreasonable given Mrs C was an elderly, frail woman with multiple health problems.  We were critical that hospital staff did not communicate with Mr C about the discharge and that the paperwork which prompts such discussions had not been completed appropriately.

We upheld both complaints and made a number of recommendations to address the issues identified.  The Board have accepted the recommendations.

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

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

Complaint number

What we found

What the organisation should do

Evidence SPSO needs to check that this has happened and the deadline

(a) and (b)

I found that there were unreasonable failings in Mrs C's care and in the Board's investigation of the complaints

Provide a written apology to Mr C for the failings identified.

The apology should meet the standards set out in the SPSO guidelines on apology available at https:www.spso.org.uk/leaflets-and-guidance

A copy or record of the apology

By:  24 January 2018

 

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

Complaint number

What we found

What should change

Evidence SPSO needs to check that this has happened and deadline

(a)

The quality of the clinical assessments and documentation by both doctors was of an unreasonable standard

Patients should receive a full assessment with all relevant information documented including: medical and medication history; and observations

Confirmation that both doctors have been made aware of the findings and had the opportunity to discuss and learn from them, including reference to any learning and development, or training, identified

By:  21 February 2018

(a)

Staff failed to perform a 12-lead ECG.

A 12-lead ECG should be used in the assessment of abdominal pain in similar cases

Evidence that relevant staff have undertaken educational activities to better understand cardiovascular disease in women and what action to take in future

By:  21 February 2018

(a)

Mrs C's discharge from hospital was not overseen by a more senior doctor and an important blood test result was overlooked

Patients should not be discharged without senior doctor oversight in similar cases.  All relevant results should be taken into account

Confirmation that Doctor 2 has been made aware of the findings and had the opportunity to discuss and learn from them, including reference to any learning and development, or training, identified

By:  21 February 2018

(a)

The Board failed to provide COPFS with the serum amylase test result

All relevant test results should be identified and provided to COPFS

Evidence that the Board have now sent this result to COPFS

Evidence that staff have been reminded of the importance of providing all relevant information at the relevant time

By:  21 February 2018

(a) and (b)

The Board's investigation of the complaints was not robust and failed unreasonably to identify the abnormal serum amylase test result

Clinicians providing input to complaint investigations should thoroughly review the care provided

Evidence that these findings have been shared with Doctor 3 with appropriate support

By:  21 February 2018

(b)

It was unreasonable to discharge Mrs C without contacting Mr C in advance

The discharge section of the clinical records should be completed in terms of relative/next of kin contact in all cases

Evidence that the Board has a process in place for auditing discharge documentation

Evidence that my decision has been shared with relevant staff with appropriate support

By:  21 February 2018

Related reading

  • Report no:
    201600834
  • Date:
    November 2017
  • Body:
    Dumfries and Galloway NHS Board
  • Sector:
    Health

Summary
Mr C, who works for an advocacy and support agency, complained on behalf of Mr A about a number of issues relating to Mr A's discharge to a nursing home following an admission to Newton Stewart Hospital.  First, Mr C complained about the length of time it took clinicians to tell Mr A that an operation to help with a complex medical condition was not going to be possible for him despite it being initially proposed.  Had Mr A known that the operation would not be possible, Mr C said Mr A would not have allowed himself to be discharged to the nursing home.  Instead, when Mr A was discharged, he believed that he would be able to return home after a short time in the nursing home following the operation.  Second, Mr C said that Mr A had not been given the option to return home with a funded care package before being discharged to the nursing home.  Third, Mr C said that board staff had failed to explain clearly to Mr A the financial repercussions of his discharge to the nursing home before discharge and then, given his mental health issues, unreasonably failed to arrange an advocate for him to help him throughout the discharge process.  Finally, Mr C said that Mr A's time in the nursing home should be considered as NHS continuing care because he was waiting for an NHS funded operation.

We took independent advice from a consultant in care of the elderly and considered guidance on choosing a care home on discharge from hospital and on hospital-based complex care (ongoing hospital care) in place at the time of the complaint.  We found that when Mr A was discharged, he did not need hospital care and so it was reasonable to discharge him given his clinical needs at the time.  Given this, we also found that the board's decision not to pay the nursing home charges was made in line with the guidance on ongoing hospital care.  In relation to the time it took the board to reach a decision about Mr A's operation, the advice we accepted was that the operation was specialist and complex and so it was reasonable for the decision to take as long as it did.  However, we identified a number of significant failings about the way Mr A was discharged.

We found that the board failed to take all reasonable steps to ensure Mr A was in a position to make an informed decision about the move to a nursing home and that an opportunity for discharge home was missed.  Staff failed to explore with Mr A the option of discharge home with a care package in a reasonable way, and failed to provide clear written information to Mr A about his discharge, particularly around the financial implications of the move.  Staff also let Mr A retain an over-optimistic view about the potential of an NHS-funded operation to improve his health when clinicians considered this was unlikely.  Finally, we found that the board should have offered advocacy services to Mr A given his mental health problems to support him during a complex and uncertain time with extremely significant implications.

We upheld two of Mr C's complaints and made a number of recommendations to address the issues identified.

Redress and Recommendations
What we are asking the Board to do for Mr A:

Complaint number

What we found

What the organisation should do

Evidence SPSO needs to check that this has happened and the deadline

(a) and (b)

The Board failed to take all reasonable steps to ensure Mr A was in a position to make an informed decision about the move to a nursing home, in line with the guidance, and an opportunity for discharge home was missed

Cover the costs of the nursing home fees Mr A has paid for the time he was in the nursing home on production of an invoice or receipt (or other evidence it was paid).

The resulting payment should be made by the date indicated: if payment is not made by that date, interest should be paid at the standard interest rate applied by the courts from that date to the date of payment

Evidence of payment

By:  22 January 2018

(a) and (b)

The Board failed to take all reasonable steps to ensure Mr A was in a position to make an informed decision about the move to a nursing home, in line with the guidance, and an opportunity for discharge home was missed

Apologise to Mr A for failing to ensure he was discharged in a reasonable way and, in particular, in a position to make an informed decision about the move to a nursing home.

The apology should comply with the SPSO guidelines on making an apology, available at https://www.spso.org.uk/leaflets-and-guidance

A copy or record of the apology

By:  22 December 2017

 

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

Complaint number

What we found

What should change

Evidence SPSO needs to check that this has happened and deadline

(a) and (b)

Staff failed to follow elements of the guidance on choosing a care home on discharge from hospital and hospital-based complex clinical care to ensure Mr A was discharged in a reasonable way

Staff should comply with the relevant guidance when arranging discharge

Evidence the guidance has been raised with relevant staff, and  that staff are complying with the terms of the guidance. This could be via  an audit, undertaken regularly, to evidence compliance

By:  22 January 2018

(a) and (b)

Staff failed to provide clear written information in line with the hospital-based complex clinical care guidance about discharge to Mr A to ensure Mr A was discharged in a reasonable way

Staff should ensure information is provided as part of the hospital based complex clinical care guidance

Evidence that the process relating to the provision of information has been reviewed to ensure it complies with guidance

By:  22 January 2018

(a) and (b)

Staff failed to offer advocacy service to Mr A to ensure he was in a proper position to make an informed choice about his discharge

Staff should ensure patients are offered advocacy services where appropriate

Evidence Mr A's complaint has been raised with the staff responsible for advising advocate services in his case in a supportive way; and to staff involved in advising advocate services in cases such as this

By:  22 December 2017

Related reading

  • Report no:
    201603186
  • Date:
    September 2017
  • Body:
    Grampian NHS Board
  • Sector:
    Health

Summary
Ms C complained about the treatment provided to her late mother (Mrs A).  Mrs A was 53 years old when she attended at Aberdeen Royal Infirmary (the hospital) with lower abdominal pain and urinary frequency.  She was discharged with plans for urgent follow-up.  Before this took place, Mrs A was re-admitted via the emergency department.  She was found to be suffering from cancer and procedures to insert plastic tubes into her kidneys to drain urine were necessary.  The procedure, called nephrostomy, is carried out when the tube linking the kidney to the bladder has become blocked.  After the nephrostomies were carried out, Mrs A later began to show signs of infection.  Although antibiotic treatment was started, Mrs A developed sepsis (a severe complication of infection) and died.

Ms C complained that Mrs A had not been prescribed prophylactic antibiotics (antibiotics given as a precaution to prevent, rather than treat, an infection) prior to the nephrostomies.  The board initially responded that there was no requirement to prescribed these and Ms C brought her concerns to this office for investigation.  A short time later, the board advised us that a hospital policy recommending the use of prophylactic antibiotics had been identified.  We suspended our investigation to allow the board to address this matter and a number of further issues Ms C raised.  After the board issued their final response, Ms C brought the complaint back to this office and we restarted our investigation.

We took advice from a consultant urologist.  We found that there had been a failure to follow the hospital policy on prescription of prophylactic antibiotics for Mrs A.  We established that Mrs A had a poor prognosis due to the extent of her cancer.  While prescribing prophylactic antibiotics may­ have prevented her from developing sepsis, it was impossible to definitively determine the effect they would have had.

Although the board latterly acknowledged its policy had not been followed, no apology was offered to Ms C for either the failing itself or for the fact its initial complaint response was inaccurate.  We upheld Ms C's complaint 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 Ms C:

What we found

What the organisation should do

Evidence SPSO needs to check that this has happened and the deadline

The Board acknowledged that the local recommendation to prescribe prophylactic antibiotic was not followed but has not apologised

Apologise to Ms C for the failure to follow local guidance.  The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance

A copy or record of the apology

By:  20 October 2017

The initial complaint response gave inaccurate information on the prescription of prophylactic antibiotics for nephrostomies

Apologise to Ms C for not giving a full and accurate response.  The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance

A copy or record of the apology

By:  20 October 2017

 

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

What we found

What should change

Evidence SPSO needs to check that this has happened and deadline

The Board has advised its intent to review the local policy on prescribing prophylactic antibiotics for nephrostomies

The local policy should provide clear guidance to clinicians on when prophylactic antibiotics are to be prescribed and by whom

Evidence that the policy has been reviewed including the choice of antibiotic, length of prescription and clear definition of the clinician responsible for prescribing

By:  20 November 2017

At the time of Mrs A's admission and the initial complaint response, staff were not following local policy

All relevant clinicians should be aware of the guidance

Evidence, such as memos, emails, training resources, to confirm that awareness of the policy has been raised with relevant staff

By:  20 December 2017

 

Feedback
Complaints handling
Due to new issues being raised by Ms C, this investigation was suspended to allow the Board to respond.  By this time, the Board had recognised that there was, in fact, a local recommendation to prescribe prophylactic antibiotics for patients like Mrs A.  This represented an opportunity for the Board to acknowledge that its original response was inaccurate and apologise.  More effective handling of this complaint could have resolved the matter for Ms C at an earlier stage without the need for this further investigation.  The Board should reflect on this.

Related reading

  • Report no:
    201605095
  • Date:
    August 2017
  • Body:
    Greater Glasgow and Clyde NHS Board
  • Sector:
    Health

Summary
Mr C complained about the care and treatment provided to his late wife (Mrs A).  Mrs A was diagnosed with bladder cancer in April 2015 and Mr C complained that both before and after the diagnosis there were delays in providing necessary appointments.  Mr C also complained that there were unreasonable delays in the treatment of Mrs A's cancer after she had cardiac surgery, and that there were failings in communication between specialists treating her.

We took advice from a consultant urologist.  With regards to delays in appointments, we found that there was an unreasonable delay between the results of a biopsy being taken and a subsequent resection.  We also found that there was an unreasonable delay from the time of diagnosis to the time that Mrs A discussed definitive management with a surgeon.  We considered these delays to be unreasonable.  We upheld this aspect of Mr C's complaint.

We also found that there was a delay in Mrs A being provided with treatment for her bladder cancer.  We identified a failure of the urology service to act upon a letter which stated that Mrs A would be suitable to go ahead with treatment for her bladder cancer in a months' time.  We further found that the possibility of Mrs A's condition deteriorating, and her treatment options, were not fully discussed with her, and that there was a delay in Mrs A being offered palliative radiotherapy.  We determined that there were multiple failings in communication between specialists treating Mrs A regarding her condition and treatment.

Mr C also complained about the board's handling of his complaint, specifically that they did not address all of the issues which he had raised.  We considered that the board had failed to address some important questions Mr C had asked, and therefore we upheld this aspect of Mr C's complaint.

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

Complaint number

What we found

What the organisation should do

Evidence SPSO needs to check that this has happened and deadline

(a), (b) and (c)
  • There were unreasonable delays in Mrs A being provided with the relevant appointments following her diagnosis of bladder cancer;
  • There were unreasonable delays in the treatment of Mrs A's cancer;
  • There were unreasonable failings in communication between the specialists treating Mrs A regarding her condition and treatment; and
  • The Board's handling of Mr C's complaint was unreasonable

Provide a written apology to Mr C for the failings identified

Copy of apology letter which meets with the SPSO guidelines on making an apology, available at https://www.spso.org.uk/leaflets-and-guidance

By:  27 September 2017

 

We are asking Greater Glasgow and Clyde NHS Board - Acute Services Division to improve the way they do things:

Complaint number

What we found

What should change

Evidence SPSO needs to check that this has happened and deadline

(a)

There was a delay between the results of the biopsy being reported on 10 February 2015 and Mrs A having a resection on 22 April 2015

In similar cases patients should receive treatment within 31 days from decision to treat to first treatment, as per the Scottish Government targets

Documentary evidence of a review of urology treatment waiting times for patients with cancer and the steps being taken to better meet National guidelines

By:  22 November 2017

(a)

There was a period of approximately two and a half months from the time Mrs A was diagnosed with muscle invasive bladder cancer to the time she saw a surgeon to discuss definitive management

In similar cases, timescales between histology reporting and out-patient appointments in the urology service should be shorter

Documentary evidence of a review of the timescales between histology reporting and out-patient appointments in the urology service and details of steps being taken to shorten timescales

By:  22 November 2017

(b)

The urology service failed to act on the letter of 3 November 2015 stating that Mrs A could go ahead with surgery for her bladder cancer in a month's time

Letters between services should be shared at the appropriate time and acted upon where necessary

Documentary evidence that this finding has been shared and discussed with relevant staff.  This could include, for example, minutes of discussion at a staff meeting or copies of internal memos, emails or notes of feedback given about this complaint

By: 25 October 2017

(b)

Mrs A was not offered palliative radiotherapy at an earlier point

Palliative radiotherapy should be considered and offered as early as possible to reduce patients' pain

Documentary evidence of the learning from this case and any subsequent changes to procedures, instructions and training provided to clinical staff

By:  25 October 2017

(b)

When Mrs A suffered the MI, her options should have been discussed more thoroughly with her and the possibility of disease progression whilst she was undergoing cardiac surgery and recovery should have been made clear

The Board should demonstrate that staff are aware of the need to ensure patients are made fully aware of the possibility of disease progression if treatment for other health issues is required; and of their options for treatment

Documentary evidence that this finding has been shared and discussed with relevant staff.  This could include, for example, minutes of discussion at a staff meeting or copies of internal memos, emails or notes of feedback given about this complaint

By:  25 October 2017

(c)

There were failings in communication between the oncology and urology teams with regard to Mrs A's condition and treatment

The Board should demonstrate that they have reflected and learned from this case to ensure that there is better communication and coordination between teams, including discussion at multi-disciplinary team meetings as appropriate, so that patients receive good and timely care

Documentary evidence that the relevant board staff have considered Ms A's case and how to ensure better communication and coordination of care between departments and hospitals.  This could include evidence such as a minute of a staff meeting; an action plan, instructions to staff and/or a revised protocol

By:  25 October 2017

(d)

The Board failed to address all of the issues that Mr C raised in his original complaint

The Board should ensure that complaint responses correctly identify and respond to all issues raised by complainants

Documentary evidence that this finding has been shared and discussed with relevant staff.  This could include, for example, minutes of discussion at a staff meeting or copies of internal memos, emails or notes of feedback given about this complaint

By:  27 September 2017

 

Evidence of action already taken
Greater Glasgow and Clyde NHS Board - Acute Services Division told us they had already taken action to fix the problem.  We will ask them for evidence that this has happened:

Complaint number

What we found

What the organisation say they have done

Evidence SPSO needs to check that this has happened and deadline

(b)

There were unreasonable delays in the treatment of Mrs A's cancer

Reviewed the pathway available to bladder cancer patients to improve the services available and the coordination of care

Copy of the bladder cancer pathway, highlighted to show the changes and/or additions

By:  27 September 2017

 

 

Related reading

  • Report no:
    201606803
  • Date:
    August 2017
  • Body:
    Grampian NHS Board
  • Sector:
    Health

Summary

Ms C complained about the care she received from Grampian NHS Board (the board).  As Ms C was experiencing post-menopausal bleeding, her GP urgently referred her to the gynaecology service of Aberdeen Royal Infirmary.

Ms C's referral was downgraded from urgent to routine by the gynaecology service.  She was offered an appointment six weeks after her GP referral.  Her GP contacted the gynaecology service on two occasions to request an earlier appointment but was told it was unnecessary for Ms C to be seen any sooner.  When Ms C contacted the gynaecology service, they agreed to bring her appointment forward by a week.  Given her concerns, Ms C was told that a consultant gynaecologist would look at her ultrasound scan report.  Ms C received a phone call from a non-clinical staff member reassuring her that she did not need an urgent appointment.

When Ms C attended her appointment at the gynaecology service, an endometrial biopsy was carried out.  When the results were issued, Ms C was diagnosed with endometrial cancer.

During our investigation, we took independent advice from a consultant gynaecologist and from a consultant obstetrician and gynaecologist.  We found that Ms C's referral should not have been downgraded to routine and she should have been seen by the gynaecology service within two weeks of her GP referral.  We found that the target for the treatment of Ms C's cancer was missed by 19 days.  We found that Ms C should not have been given reassurance about the findings of her ultrasound scan report as they could have indicated cancer.  We also found that this reassurance should not have been given to Ms C by a non-clinical staff member.  We upheld Ms C's complaint.

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

What we are asking The Board, to do for Ms C:

Complaint number

What we found

What the organisation should do

Evidence SPSO needs to check that this has happened and the deadline

(a) and (b)

There was an unreasonable delay in giving Ms C a gynaecology appointment and a delay in treatment after her diagnosis.

Ms C was given inappropriate advice about her ultrasound scan results by a non-clinical member of staff

Provide a written apology which complies with the SPSO guidelines on making an apology, available at https://www.spso.org.uk/leaflets-and-guidance

A copy of the apology letter.

By:  2 October 2017

 

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

Complaint number

What we found

What should change

Evidence SPSO needs to check that this has happened and deadline

(a)

There was an unreasonable delay in the gynaecology service offering Ms C an appointment

Patients with postmenopausal bleeding should be offered a gynaecology appointment in line with the NICE guidelines [NG 12]

Documentary evidence of the steps to being taken to prevent similar failings in future cases, such as an action plan, instructions to staff, revised guidance

By:  30 October 2017

(a)

There was an unreasonable delay in treating Ms C's cancer

In similar cases, patients should receive treatment within 62 days of referral as per the Scottish Government targets

Documentary evidence of the steps being taken to reduce waiting times for treatment

By:  30 October 2017

(a)

The Board’s vetting guidance on endometrial cancer is incorrect

The guidance should be updated urgently taking into account NICE guidance

New or updated guidance, highlighted to show the changes and/ or additions

By:  2 October 2017

(b)

Ms C was given inappropriate advice about the ultrasound scan results

Staff should reflect and learn from the adviser’s comments in relation to the ultrasound scan results

Documentary evidence that this decision has been shared and discussed with staff.  This could, for example, include minutes of discussions at a staff meeting or copies of internal memos/emails, or notes of feedback given about this complaint

By:  30 October 2017

(b)

Ms C was given clinical advice by a non-clinical member of staff

The Board (including staff) should reflect and learn from the adviser's comments about the inappropriateness of non-clinical staff giving clinical information to patients

Documentary evidence that this decision has been shared and discussed with staff.  This could, for example, include minutes of discussions at a staff meeting or copies of internal memos/emails, or notes of feedback given about this complaint.

By:  30 October 2017

 

Related reading

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