Health

Summary
Ms C, a support and advocacy worker, complained on behalf of Ms B about the care and treatment provided to Ms B's son (Mr A) when he was admitted to Balfour Hospital (the hospital) following a road traffic accident.  Ms C said that when Mr A arrived at the hospital his spine was not x-rayed despite him reporting pain in his back, and that when Mr A was later transferred to another hospital it was found that he had a spinal fracture.  Ms C also complained that a wound to Mr A's leg was not cleaned appropriately and said this led to infections.

We took advice from an emergency consultant and an orthopaedic surgeon.  We found multiple significant failings in the care and treatment provided to Mr A.  These included a failure to examine and x-ray Mr A's spine; a failure to obtain
x-rays of Mr A's neck, chest and pelvis; a failure to assess and clean a wound in Mr A's arm in a timely manner; a failure to administer antibiotics in a timely manner; and a failure to administer appropriate pain medication.  We also found that the treatment provided was not appropriately documented in the medical records.  However, we determined that Mr A's leg wound was appropriately cleaned and therefore did not uphold this aspect of Ms C's complaint.

We had further concerns that the board's own investigation into Ms C's complaint failed to identify the serious clinical failings in this case and made recommendation regarding this.

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:

Summary
Mr and Mrs C complained about the management of Mrs C's pregnancy, leading up to the stillbirth of their baby.  Mrs C experienced increased blood pressure during pregnancy, as well as slightly raised urine protein levels.  These can be signs of pre-eclampsia (a condition that can affect pregnant women, particularly during the second half of pregnancy, which can lead to serious complications for both mother and baby).

About 38 weeks into Mrs C's pregnancy, a plan was made for induction in a week's time.  In the meantime, Mrs C was admitted overnight for monitoring of her high blood pressure, and she also attended a follow-up appointment where a cardiotocography (CTG) was carried out.  The CTG showed some problems of loss of contact and deceleration of heartbeat, but staff thought this was due to Mrs C's movements, and she was discharged.  Sadly, when Mrs C returned two days later for the induction, her baby was found to have died (he was stillborn the next day).  Mr and Mrs C gave consent for a post-mortem examination, which showed Mrs C's placenta had not been functioning properly, which was consistent with pre-eclampsia.

Following discussion with the consultant in charge, Mr and Mrs C complained to the board.  While the board had begun carrying out a routine review of Mrs C's care (which they do for all stillbirths), they also carried out a further clinical review of the care (the REI review) in response to the complaint.  This review found that there was no clear diagnosis made between gestational hypertension (high blood pressure) and pre-eclampsia for Mrs C.  It found that the local guidance about when to measure urine protein levels (a test for diagnosing pre-eclampsia) differed from the National Institute of Health and Care Excellence (NICE) guidelines about this.  The REI review also found there was a lack of continuity of care, and the way that records were kept made it difficult to identify trends in blood pressure recording and blood results in this case.

Following the REI review, the board put in place an action plan for improvement, including amending their guidelines to be consistent with NICE guidelines.  However, the results of the REI review were not shared with Mr and Mrs C.  While the board intended to share the results, they felt it would be easiest to do this in a meeting.  A complaint response had already been drafted before the REI review was finished (indicating that the management of Mrs C's pregnancy was reasonable), and the board simply added a line stating that a review had been carried out and inviting Mr and Mrs C to contact them for a meeting.  The rest of the letter was not updated to include the outcomes from the REI review.

After taking independent clinical advice from a midwife and two obstetrics and gynaecology consultants, we upheld Mr and Mrs C's complaint about the management of her pregnancy.  We found the board failed to conduct further tests to clarify Mrs C's diagnosis (between high blood pressure and pre-eclampsia), contrary to NICE guidance.  We also found the board had failed to recognise abnormalities on two CTG recordings.  We did not uphold Mr and Mrs C's complaints about the continuity of care, their involvement in the REI review or the bereavement support made available to them, although we gave the board some feedback on these points.

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

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

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

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:

Feedback
Complaints handling:  It was good practice by the Head of Midwifery/Nursing to escalate this complaint for a multi-disciplinary REI review (due to her concerns about the draft complaint response).  However, the results of the REI review were not reflected in the final complaint response, and were never provided to the family (other than an offer to meet and discuss the results, which was not followed up when the family did not get in contact).  If the Board had shared the REI review results and made appropriate apologies, this complaint might have been resolved earlier.

Response to SPSO investigation:  The Board responded promptly to our enquiries.

Points to note:  The professional advisers raised several points for the Board's consideration:

• In relation to continuity of care, Adviser 2 suggested the Board could consider how often women undergoing surveillance for high blood pressure are booked to see their own consultant (for example, in an antenatal clinic), so that decisions could be made with more continuity.
• In relation to the REI review, Adviser 3 suggested the Board may wish to review their guidance on clinical reviews prompted by complaint investigations, to ensure that families who wish to be involved in a review have this opportunity.
• In relation to support following a stillbirth, Adviser 1 said it is good practice for maternity units to have at least one member of staff who has specialist knowledge and training in bereavement care, and recommended that the Board should seriously consider and agree the business proposal for a bereavement midwife.

Summary
Mrs C complained that the practice failed to take appropriate action when her late father (Mr A) presented to them reporting symptoms of back pain.  Mr A was 81 years old at the time and Mrs C considered that the GPs failed to recognise potential underlying symptoms and arrange appropriate investigations.  Mr C was initially given pain medication and told to return if his symptoms did not improve.  When his symptoms had not improved by the following month, a referral was made to urology for further investigation.  Shortly after this, Mrs C removed Mr A from the practice and took him to live with her.  He was subsequently diagnosed with terminal cancer.

We took independent GP advice, which noted that the GP elected to refer Mr A to urology due to his history of raised prostate-specific antigen (PSA).  This is a protein produced by cells of the prostate gland, levels of which can indicate prostate cancer or other problems with the prostate.  Mr A had been diagnosed two years previously with benign prostatic hyperplasia (BPH) - an enlarged prostate gland - and he was prescribed medication for this.  Mr A’s PSA had last been checked around this time and we were advised that this should have been followed up by the practice with an urgent urology referral, rectal examination, and repeat blood tests.

The next clinical prompt for checking Mr A’s PSA was when he presented with back pain but this was not done.  We were advised that new onset back pain in a man of Mr A’s age should have been a red flag sign and should have prompted further investigations and/or specialist referral.  The practice acknowledged that further investigations should have been carried out, including a check of Mr A’s PSA.  We were also advised that Mr A’s PSA should have been re-checked at the time of referring him to urology and, again, the practice acknowledged that this should have happened.  It was also noted that the referral was sent on a routine basis, when we were advised it should have been given an urgent priority.

We found nothing to link the identified failings to Mr A’s death.  His death certificate recorded gastric cancer and no prostate cancer diagnosis was evident.  However, we were advised that the actions taken by the GPs were unreasonable irrespective of the cause of death.  We found it particularly concerning that their knowledge of Mr A’s history of raised PSA, and lack of follow-up in this regard, did not appear to have prompted a higher degree of suspicion when he presented with new onset back pain.  In the circumstances, we upheld the complaint.  While we were satisfied that the practice had ultimately demonstrated adequate reflection, we considered that there were earlier opportunities for them to have recognised the noted failings.  In particular, they carried out a significant event analysis which did not identify any shortcomings in the care provided.

Redress and Recommendations
The Ombudsman recommends that the practice:

• apologise to Mrs C for the failings this investigation has identified; and
• ensure that the Practice team involved in carrying out significant event analyses have familiarised themselves with the relevant NHS Education for Scotland guidance and report back to the Ombudsman when this has been done.

Summary
Mrs C complained about the care and treatment provided to her brother, (Mr A) by Lanarkshire NHS Board (the board).  Mr A had been experiencing pain in his legs, feet and ankles.  He was referred to the deep venous thrombosis (DVT) service at Hairmyres Hospital (the hospital) by his general practitioner and DVT was ruled out as a cause of his symptoms.

Mr A later had a circulation assessment at one of the board's community clinics (the clinic).  Staff at the clinic were unable to find a pulse in Mr A's foot.  Attempts were made to contact the vascular service at the hospital by telephone but there was no reply and a message was left on an answering service.  Mr A returned home. Five days later, however, one of his toes turned black and Mrs C took him directly to the hospital.

A scan showed that Mr A had a blockage in one of the arteries in his thigh and a procedure was suggested to remedy this.  The procedure was not carried out for a further three days during which time Mr A became increasingly unwell.  This deterioration continued after the procedure and Mr A had to undergo an above the knee amputation of his leg.

During our investigation, we took independent advice from a consultant physician and a vascular surgeon.  While we found no issues with the DVT service examination, we identified that the referral pathway from the clinic to the vascular service had failed.  We found that this and the delay in conducting the procedure meant that the board had failed to take appropriate, timely action to try to save the limb.  While unable to definitively determine that the loss of Mr A's leg was avoidable, we considered more urgent action would have given him the best chance of a different outcome.   We upheld Mrs C's complaint.

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

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

We are asking the Board to improve the way it does things:

Feedback for the Board
Adviser 2's comments on the subjectivity of clinical judgement in assessing pulses should be circulated to relevant staff for learning purposes.

Summary
Mrs C complained about the care and treatment her husband (Mr C) received at the Victoria Hospital, Kirkcaldy.

Mrs C said that her husband suffered a fall getting out of bed while on holiday abroad which had caused him to hit his head and lose consciousness for approximately ten minutes.  On arrival home a few days later, Mr C attended the hospital's emergency department.  He was treated as a minor head injury and discharged home the same day with head injury advice.  Mrs C complained that Mr C was not provided with appropriate treatment, and, in particular, that a CT scan was not carried out.

Eleven days later, Mr C returned to the hospital as he had a constant headache.  Mrs C said that, although on this occasion a CT scan was carried out, she had to beg staff to carry it out.  The scan showed Mr C had suffered a brain haemorrhage.  He was transferred the same day to another hospital where he had a craniotomy for an acute subdural haematoma.

Mr C was subsequently transferred back to the Victoria hospital and admitted to a ward.  Mrs C was unhappy with the nursing care Mr C received there.

During our investigation we took independent advice from three advisers:  a consultant in emergency medicine, a consultant neurosurgeon and a nurse.  We found that given his presenting symptoms, an urgent CT scan of Mr C's head should have been carried out when he first presented to the emergency department, and the decision not to do was a significant and serious failing.  We also found that the failure to carry out a CT scan had delayed Mr C's diagnosis and treatment and adversely affected his outcome.  If the diagnosis and treatment had been made sooner there would in all probability have been a significantly improved prognosis for Mr C.  Given this we upheld this aspect of Mrs C's complaint.

We considered, however, that the treatment Mr C received when he returned to the emergency department was timely and was of an excellent standard.  Therefore, we did not uphold this part of Mrs C's complaint.

In relation to the nursing care which Mr C received, the board said they had identified a number of issues where Mr C's care and their communication with Mrs C had at times fallen short of the standard Mrs C expected and they had apologised.  The board said these matters were also addressed with the nursing staff concerned.  We received advice that Mr C's brain injury had caused him to exhibit behaviour which was at times difficult for staff to manage.  While there were many aspects of Mr C's nursing care which were reasonable, we found that he should have been observed for falls better.  We also identified shortcomings in how Mr C's nursing records were kept.  We considered that, on balance, and in the circumstances of this case, the nursing care provided to Mr C was not reasonable and we therefore upheld this aspect of Mrs 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 and Mrs C:

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:

Feedback for Fife NHS Board
Complaint Number (c)
Points to note:  Given the comments of Adviser 3, the Ombudsman recommends the Board give consideration to having a dedicated ward/part of a ward where patients who have suffered a brain injury and/or exhibit challenging behaviour can be cared for jointly by acute and mental health teams with appropriate staffing levels. 

When responding to a draft of this report, the Board told me that, having considered it, it would not be practicably possible to deliver the point noted in my feedback.  Even so, they will make every effort to accommodate patients with this presentation within two specific wards of Hospital 1 where they have an acute psychiatric liaison service/unscheduled care team.  The Board have also informed me that the supervision procedure for patients requiring one-to-one intensive supervision is currently under review.  It is ultimately a matter for the Board, and I am pleased that they considered the feedback in relation to their services, seriously.

Summary
Mrs C complained about the delay in arranging an endoscopy procedure for her late husband (Mr C).  She said that although Mr C's GP requested an urgent referral for him, the required procedure was not undertaken until more than three months' later.  At this time, a malignant tumour was found in his oesophagus which was later determined to be inoperable.  Mr C died seven months after this.

Mrs C complained to the board who said that as Mr C's review was not marked 'urgent suspicion of cancer', it was not upgraded to be seen with the highest priority at a time when there were substantial waiting time delays for endoscopy procedures to be carried out.  The board accepted that there had been a delay and said that they were planning to put procedures in place to increase their capacity to meet endoscopy waiting time targets.

We obtained independent clinical advice and found that the board's approach had not been a reasonable one in that there were too many priority streams for grading the urgency of endoscopies.  There was already sufficient clinical information available for Mr C's case to have been triaged as a suspected cancer case and, from the available guidance, it appeared that Mr C's GP had followed the instructions given.  We upheld the complaint.

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:

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:

Summary
Mrs C complained to us about the care and treatment provided to her late son, (Baby A), at the Aberdeen Royal Children's Hospital.  Baby A had been fitted with a shunt (a medical device that relieves pressure on the brain by draining excess fluid into the abdominal cavity) shortly after he was born.  Mrs C complained that when he was admitted to the hospital several months later, there were multiple failings in care and treatment.  Baby A passed away in a specialist paediatric neurosurgery centre under another health board a few days after his admission to the hospital.

During our investigation, we took independent advice from a paediatrician, a neurosurgeon, and an anaesthetist.  We found that although the board's internal investigation had identified some issues in Baby A's care and treatment, they had not addressed the important issues with the episode of care.  Our investigation determined that there was a lack of clarity regarding the roles of each medical team, and that there was a lack of communication between consultants when Baby A's condition was not improving.  We also found that the neurosurgical team had not kept reasonable records, nor had they appropriately assessed Baby A before and after operations.  We identified significant delays in Baby A being reviewed after he underwent operations, and a delay in clinicians contacting the specialist centre for advice on the management of Baby A.  Finally, we considered there to have been a lack of communication from the neurosurgical team and Baby A's parents.  Given the multiple failings identified by our investigation, we upheld this aspect of Mrs C's complaint.

Mrs C further complained to us that after Baby A's death, the board did not contact her or communicate with her until she submitted her complaint.  The board accepted that this was unacceptable, and we upheld this aspect of Mrs C's complaint.

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 to the Ombudsman about the care and treatment he received during a three-week admission to Wishaw General Hospital, when he developed a pressure ulcer which required district nursing care for five months after his discharge.  Mr C said that nursing staff did not take sufficient action to monitor his risk of developing a pressure ulcer.

My complaints reviewer took independent medical advice on Mr C's case from a nurse.  The adviser said that the nursing staff unreasonably failed to recognise that Mr C was at high risk of developing a pressure ulcer and, therefore, failed to provide care/assess Mr C using the SSKIN care bundle (a five-step care plan for pressure ulcer prevention).  The adviser said the Malnutrition Universal Screening Tool or MUST (a way to screen patients to identify and treat adults at risk of malnutrition) was completed inaccurately on all three occasions it was completed.  Had concern about Mr C's weight loss been noted in the MUST and the correct score applied, this would have resulted in Mr C being deemed at high risk of developing a pressure ulcer and a high risk care plan being used.  If the nursing staff had assessed Mr C correctly and used the SSKIN care bundle, it is likely that he would not have developed a pressure ulcer.  The board have acknowledged that they did not carry out visual inspections of Mr C's pressure areas and I am critical of them in this regard.

The adviser said that the fact that Mr C developed a pressure ulcer in the hospital which appeared to require district nursing care for five months after Mr C's discharge, suggested that the nursing staff failed to provide Mr C with appropriate pressure area care and they considered the board's failing to be significant.  I, therefore, upheld Mr C's complaint.  I am also concerned that during their own investigation of Mr C's complaint, the board did not recognise the failings in Mr C's care and take appropriate remedial action.

Redress and Recommendations
The Ombudsman recommends that the Board:

• feed back my decision on this complaint to the staff involved;
• ensure that in future nursing staff carry out appropriate assessment and monitoring of patients at risk of developing pressure ulcers;)
• ensure that in future, staff carry out a full and proper investigation of patients' complaints and recognise failings where they exist; and
• provide Mr C with a written apology for the failings identified and offer to meet with him to discuss their learning and actions as a result of his complaint.

Summary
Ms C complained about the treatment she received when she saw a dentist after a bridge that replaced some of her teeth had come off.  She said that the dentist had inadvertently fractured the porcelain when cleaning the bridge.  She said that they then made a temporary repair, but on the following day, part of the bridge shattered.

We took independent dental advice on Ms C's complaint.  The adviser noted the bridge had been in need of replacement, but that there had been a lack of care by the dentist in fracturing the porcelain on the bridge.  We therefore upheld this aspect of Mr C's complaint.  However, we found that, as this had been an emergency appointment, it had been reasonable for the dentist to carry out a temporary repair and then refer Ms C to her usual dentist for further treatment.

Ms C also complained about the care and treatment she received when she saw her usual dentist.  They agreed to refer her to a consultant in restorative dentistry.  The consultant sent a report to Ms C's usual dentist with their findings after examining Ms C.  In their report, they said that she may need to have some teeth extracted, but they would be quite hopeful that another tooth was relatively sound and could be used to support a bridge.  They also suggested that she could have orthodontic treatment for this tooth and implants to replace the teeth that were to be extracted.  However, after receiving the report, Ms C's usual dentist extracted this tooth along with the other teeth supporting the bridge.

We also took independent dental advice on this aspect of Ms C's complaint.  We found that there was no evidence that Ms C had been adequately advised of her options for replacing the original bridge.  Ms C's usual dentist had also failed to record his reasons for extracting what the consultant thought was a relatively sound tooth.  We did not consider that there was evidence that Ms C's usual dentist had provided reasonable treatment to Ms C and we also upheld this aspect of her complaint.

Finally, Ms C complained that the dental practice had failed to reasonably respond to her complaint about the dental treatment.  We found that the practice had acted in line with their policy for handling patient complaints.  In addition, their response about the porcelain fracture on the bridge had been reasonable.  However, the practice had failed to respond adequately to Ms C's comments about unnecessary work being carried out.  In view of this, we upheld the complaint.

Redress and recommendations
The Ombudsman recommends that Dentist 2:

• issues a written apology to Ms C for the failure to record that they adequately advised her of the reasons for extracting tooth 12 or the options in respect of the replacement of the failed bridge; and;
• in the event that they are unable to provide an x-ray showing that it was reasonable to remove tooth 12, they should refund Ms C for the cost of having to have an implant fitted to replace tooth 12, due to the failure to record why they did not follow the advice of the dental hospital or that they had fully discussed this with Ms C.  This should be done on receipt of appropriate invoices when treatment has been completed.

The Ombudsman recommends that the Practice:

• issue a written apology to Ms C for the failure to adequately investigate or respond to her comments about unnecessary work being carried out.

Summary
Ms C complained on behalf of her son (Mr A) about the care and treatment he received following a road traffic accident. Ms C said Mr A had suffered a serious injury to his arm in the accident, which had required two operations.  Following surgery, Mr A was transferred for a third operation to another NHS board.

Ms C said she was told following the third operation that Mr A's original surgery had not been properly performed and had had to be revised.  She was told that the original surgery had damaged a nerve in Mr A's arm and that he had developed a life-threatening infection.

Following her complaint to the board, Ms C and her son met the board.  Ms C said the board would not explain why Mr A's first operation had been incorrectly carried out.  Ms C also believed that her son's infection had been caused by a failure to clean his wounds correctly and that the board should have identified this sooner.

We took independent medical advice from a consultant orthopaedic surgeon on the standard of care provided to Mr A.  The adviser said that the board's position that Mr A's operations had been properly performed and his nerve left in the correct position was not logical.  Mr A had as a consequence suffered further damage to his nerve.  The adviser noted that Mr A's wounds were heavily contaminated and at high risk of infection.  However, the cleaning of his wounds and provision of antibiotics to prevent infection were carried out to a reasonable standard.  Overall, we found the board had failed to provide Mr A with a reasonable standard of care and treatment.  We were highly critical of board's failure to acknowledge that Mr A's surgery had not been carried out correctly, resulting in damage to the nerve in his arm.

We also found that the board's handling of Ms C's complaint was inadequate as it did not properly acknowledge the failures in care, despite the board being aware of these at the time.  We found that the board had failed to handle Ms C's complaint in an open and transparent manner and failed to address the concerns of the family properly.

Redress and Recommendations
The Ombudsman recommends that the Board:

• carry out a significant event analysis ensuring that Surgeon 1 reviews the findings of Operation 3; and
• provide evidence that Surgeon 1 has reflected on the failings identified in this report as part of their appraisal process;
• review their complaints investigation in light of the comments from the Aviser and provide Ms C with a full explanation for the findings of Operation 3; and
• review their handling of Ms C's complaint in order to identify areas for improvement and ensure compliance with the 'Can I help you' guidance.
• apologise unreservedly in writing to Ms C and Mr A for the failings identified in this report.