Health

Summary

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

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

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

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

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

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

Feedback

Response to SPSO investigation

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

Summary

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

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

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

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

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

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

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

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

Summary

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

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

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

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

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

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

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

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

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

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:

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

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

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:

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

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.

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:

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



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:

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 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:

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

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.

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:

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

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:

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