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:

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

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.

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:

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

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:

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:

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

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: