Health

Summary

C complained about the care and treatment that they received in respect of their cancer. C was diagnosed with colorectal cancer which had spread to their liver and required surgery. The surgery was to be performed in two stages. C complained that the second surgery was not performed within a reasonable timescale and about poor pain relief following the second surgery.

The board apologised to C for the poor communication about the arrangements for the second surgery and explained that repeating imaging was required before arranging the surgery and that they did not consider the delay to be significant. The board provided an overview of the pain relief provided and noted that any issues identified were addressed at the time.

We took independent advice from a colorectal and surgical consultant. We found that communication with C about when they could reasonably expect to have their second surgery was poor and there was an unexplained delay in their case being reviewed by the multi-disciplinary team. This resulted in a delay of around one month, however we did not consider this would have caused further spread of C’s cancer. We upheld this complaint.

We noted that there were some issues with the equipment used to deliver pain relief post surgery, however these were rectified and appropriate additional pain relief was provided promptly. We found the post surgical care and treatment provided to be reasonable and we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• That the board review their approach to communication with patients to ensure that cancer patients are proactively kept informed of progress in their treatment plan.
• That the board review their processes for prioritising the review of important cases by the MDT to ensure that such cases are progressed without delay.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C, an advocate, complained on behalf of A about treatment that they received after sustaining a knee injury. A ruptured the anterior cruciate ligament (ligament connecting the thigh bone to the shin bone) and underwent an arthroscopy of the knee (a type of keyhole surgery). This was followed up with a second surgery at a later date to complete the reconstruction of the ligament.

During the surgery, the surgeon’s scalpel snapped and to remove the tip of the blade, the surgeon had to create a larger incision. C raised concerns about the actions taken following the incident. The board acknowledged the incident and explained that damage to instruments is a rare but known complication of surgery.

We took independent advice from a consultant orthopaedic surgeon. We found that when the blade snapped, appropriate care was provided to A. It was appropriate to create a larger incision and the incident was appropriately communicated to A. However, we found that whilst a datix incident report was completed, a more in-depth investigation could have been carried out. There was no evidence that the board considered either the possibility of improper use of the instrument or that there was a defect in the instrument. We also considered that the board should have discussed the incident at a departmental level. In conclusion, we upheld C’s complaint about care and treatment in relation to the initial surgery. We did not uphold the complaint about the post operative care provided to A as we were satisfied it was reasonable.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to thoroughly investigate the adverse event where by the scalpel broke during A’s surgery. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Operation notes should be sufficiently detailed, particularly when an adverse event has occurred.
• The board should ensure that adverse events are thoroughly investigated and that appropriate reflection and learning is identified.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained on behalf of their spouse (A) who was admitted to hospital with pain, spams and weakness in their right leg which was later diagnosed as being caused by an infection in the iliopsoas muscles (a group of muscles running from the lower spine to the thigh). A is a dialysis patient and had also previously suffered a stroke, leaving them with weakness on the right side and wheelchair bound. C therefore usually supports A with dialysis and medication.

The complaint centres around an incident in the first week of A’s admission when both C and a nurse separately administered A’s evening medication. C stated that they had previously been given the medication by ward staff to support A. C had administered the evening medication and gone out for a few hours. On return, they had found A to be unresponsive. A nurse said that they had also administered evening medication. C complained that this overdose of medication had occurred and that record keeping and incident management had been unreasonable.

We took independent advice from a nursing adviser. We considered that this incident should not have happened, and that it indicated a lack of clarity, process, recording and communication within the ward.

We found that record keeping before and after the incident had been lacking, as there had been no clear record in a person centred care plan to state that the medication was being held and administered by C, that there had been a 24 hour gap in nursing records over the period of the incident and that no extra observations or conversations with a doctor had been recorded following the incident. We found that categorisation and management of the incident had been unreasonable. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for poor record keeping. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C and A that an extra dose of medication was administered. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment that they received from the board’s neurology department. C had been reporting symptoms to the board for several years before obtaining spinal surgery abroad. After surgery, C experienced improvement in their symptoms. C complained that the board did not reasonably investigate or offer treatment for their symptoms.

We took independent advice from a neurologist and neuroradiologist (a specialist in reading medical images of the spine). We found that the board had reasonably investigated C’s symptoms and offered reasonable treatment for C’s symptoms. We found that there was no missed opportunity to identify any physical problem in C’s spine that may have caused C’s symptoms, based on MR (magnetic resonance, a type of medical imaging) images of C’s spine. Therefore, we did not uphold C’s complaint.

Summary

C complained about the care and treatment that their late parent (A) received from the board. C complained that the board failed to reasonably treat an ulcer on A’s toe or manage their related pain. C also complained that A was unreasonably transferred to a nursing home from the ward when they were too frail and unwell to leave the care of the hospital. C advised that the communication with them in relation to A’s transfer was unreasonable, both in the way the matter was discussed with them by the social worker and as the ward failed to explain that their parent was nearing the end of his life. C said that they were only made aware of this by a GP at the nursing home who explained A was receiving end of life care.

The board's response to C’s complaint confirmed that A had received treatment for their toe ulcer during their inpatient admission, with follow-up treatment planned following their discharge to the nursing home.

On the matter of A’s referral to nursing home care, the board advised that this had been discussed with C by phone. The board said that the documentation of the phone call reflected that C was in agreement with the plan, with the purpose of the referral being to arrange long term care for A. Prior to discharge, A was reviewed by a ward doctor and it was determined that they were fit for discharge based on their improving blood results following a recent chest infection and as their observations were stable. The board expressed regret that A returned to hospital 10 days later having deteriorated since leaving hospital.

We took independent advice from a consultant physician and geriatrician. We found that a plan to manage A’s toe ulcer had been put in place and that they advised that A had received pain relief as required. We considered that the plan of care made by the board was reasonable.

In reference to A’s discharge to the nursing home, we found that this had been arranged in discussion with C, noting that A was not suitable for further rehabilitation, and that their cognitive function now prevented them from living safely at home. We considered the plan of care made for A in terms of their long term care needs was reasonable and in keeping with their circumstances. Therefore, we considered that the care and treatment provided by the board to A had been reasonable. We did not uphold the complaint.

Summary

C complained about the care and treatment that they received from the board following a stillbirth. C complained that the board had failed to provide them with adequate support following the birth of their child. C also complained that a consultant had acted unreasonably by discussing their child’s post mortem results with them, without prior warning and without the presence of their partner, during a consultation several months later to discuss the progress of a new pregnancy.

The board did not identify any failings with the support provided to C. However, they apologised for the distress caused to C during the meeting with the consultant. They said that the consultant was required to make a plan of care for the new pregnancy and that this inadvertently led to the discussion and counselling of C’s previous pregnancy. The Board said that C’s partner was unable to attend the meeting due to restrictions on hospital visiting in force at the time due to the pandemic.

C remained unhappy and asked us to investigate. C complained that the support provided to them was inadequate. C also complained that the consultant had acted unreasonably.

We took independent advice from a consultant obstetrician. We found that inpatient care discharge arrangements, including handover of C’s care to community midwives was as expected. We did not uphold this complaint. However, we found that there had been a failure to adequately prepare for C’s consultation. In the circumstances, we found that it was unreasonable to have progressed with C’s consultation without offering them the choice of re-scheduling so that consideration could have been made to their partner attending, or offering a remote appointment. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The findings of this investigation should be fed back to the staff involved, in a supportive manner, for reflection and learning.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the practice on behalf of their spouse (A). A is paraplegic (affected by or relating to paralysis of the legs and lower body) and was receiving district nursing treatment for various wounds, including one on the large toe of their left foot. The condition of A’s left foot deteriorated and they were showing signs of infection. A was seen by a district nurse who took photographs of A's foot and showed them to the duty GP at the practice. The GP made an urgent referral to vascular surgery, which was sent the next day, but did not assess A themselves or communicate the management plan to them. A’s condition worsened and a few days later they required immediate admission to hospital and urgent surgery. A subsequently required amputation of some of their toes. C complained that A’s outcome may have been better had they been assessed by the duty GP and/or admitted to hospital the same day.

We took independent GP advice. We were not critical of the fact the duty GP did not carry out a face to face assessment of A. We found that the GP followed the relevant guidelines by making an urgent referral to vascular surgery, which was a reasonable assessment. However, we found that the GP should also have made direct contact with the vascular surgery team for advice as to whether A required to be seen the same day. We found that the GP also should have communicated their management plan to A and to C, as they acknowledged in their complaint response. This would have allowed the opportunity to raise any concerns with the GP directly. On balance, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the communication failings we have identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• When making an urgent referral to vascular surgery for a patient with critical limb ischaemia, GPs should contact the vascular team directly for advice as to whether same day assessment is required. GPs should discuss the management plan with the patient.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C, an advocate, submitted a complaint on behalf of the family of A. A was a resident of a care home and attended hospital with low potassium levels. A later sustained a leg fracture around the time of the first discharge and was re-admitted to hospital. A later died. C complained that the nursing and medical care provided by the board was unreasonable.

We took independent advice from a nurse, consultant orthopaedic surgeon and consultant geriatrician. We found that there were failings in the nursing and medical care provided and that the board failed to carry out a reasonable investigation into the concerns raised. We also found that A did not receive appropriate care and treatment after they sustained a leg fracture. Specifically, there was a lack of recorded consultant input, delays in having a second cast fitted and delays with A being discharged afterward.

In addition, the concerns raised regarding how the leg fracture occurred weren’t appropriately investigated across multiple agencies and it took a number of contacts by both C and the SPSO before a full response was provided. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for the failings identified in relation to the investigation and treatment of A’s fracture and their discharge from hospital. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Consultant ward rounds, particularly at the weekend, should review all patients and should be documented.
• Frail elderly patients with fractures should receive appropriate orthogeriatric support.
• Patients should be discharged as soon as clinically appropriate following treatment.
• When harm comes to a patient and there are multiple organisations involved as to where the injury may have occurred, a multi-agency review is carried out in a timeous manner.

In relation to complaints handling, we recommended:

• Evidence that the learning from this complaint has been shared at an Acute Sector Clinical Governance Group.
• Evidence that the learning from this complaint has been shared via the Acute Sector Clinical Risk Management Group.
• Evidence that the learning from this complaint has been shared via the Board’s Clinical Governance structures.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C, an advocate to A, complained on behalf of A that their colonoscopy was performed without sedation or anaesthetic. A was advised at pre-assessment that they could not have pain relief during the procedure, due to having taken methadone prior to the colonoscopy. C also complained about the lack of information on the patient leaflet for methadone users, the attitude of staff, and that the procedure was performed by a trainee endoscopist.

The board considered that the care and treatment provided to A was reasonable as A consented to the colonoscopy being carried out without pain relief and understood that a trainee would undertake the procedure. The board apologised for the comments made by staff.

We took independent advice from a colorectal surgeon. We found it unnecessary to contain methadone specific information on the patient leaflet as all medication should be considered when administering sedation for all patients. We found that the advice given at pre-assessment was incorrect. There is no contraindication (a specific situation in which a medicine, procedure, or surgery should not be used because it may be harmful to the person) for use of sedation with methadone and being on methadone does not preclude either sedative or opioid pain control. Therefore, we found that A should have been given pain relief during the colonoscopy. We also found that it is the endoscopist's responsibility to understand drug interaction in prescribing medication for pain and sedation and that was not the case in this instance and a second opinion should have been sought. Due to the absence of pain relief, we found that this procedure should have been performed by an experienced endoscopist, to ensure correct technique and minimise the discomfort experienced by A. As such, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• All staff are familiar with the relevant BNF and AOMRC guidance.
• All staff are reminded of the importance of seeking specialist advice in complex or unusual cases.
• Endoscopists to be aware of the importance of technique when minimising discomfort for the patient.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

A was diagnosed with severe heart valve stenosis (when a heart valve narrows and blood cannot flow normally) and was informed that they required heart valve replacement surgery. A referral was made to a specialist unit within another health board. However, A died whilst awaiting surgery, during the early months of the COVID-19 pandemic.

C complained that there was a delay in providing A with treatment, and that when A’s condition appeared to deteriorate, they were prescribed only water tablets. C also felt that there was a lack of communication from the Cardiology Department. Additionally, C pointed to a Significant Adverse Event Review (SAER) carried out by the hospital to whom A had been referred, which had concluded that the referral had been, in their view, wrongly categorised as “routine” as opposed to “urgent”. C felt that the care provided to A had been unreasonable.

We took independent advice from a consultant cardiologist. We found that it was unreasonable that A was not referred more urgently for surgical consideration, noting that even before the COVID-19 pandemic a routine referral could take up to 18 weeks. We were also critical of the lack of formal arrangements made to keep A under regular review. A was diagnosed with severe chronic obstructive pulmonary disease (COPD) and we found that this was a missed opportunity for A’s management plan to be reviewed. Additionally, we found that we were unable to establish whether the risks of surgery were ever explained to A or whether they were given the choice of treating their symptoms with drug therapy alone. Given the importance of this, we would have expected to see evidence of this in A’s case notes. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients with congestive heart failure should be appropriately assessed with consideration given to having an urgent echocardiography (a scan used to look at the heart and nearby blood vessels) and an in-patient cardiological review. Patients being referred for more specialist investigation or treatment should be appropriately categorised in terms of urgency in relation to their condition. Patients diagnosed with severe aortic and mitral stenosis should be kept under regular clinical review. The risks of surgery and choices of available treatment should be explained to a patient and any discussions about this should be recorded in the patient’s records.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.