Health

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.

Summary
Mrs C complained about the care and treatment provided by the board to her late husband (Mr A).  Mr A was diagnosed with pseudomyxoma peritonei (a very rare type of cancer that usually begins in the appendix) and the clinicians involved in his care decided to arrange for scans to be carried out every six months to monitor any development of the cancer.  However, after two scans, further follow-up was not arranged.  Mrs C complained that Mr A did not receive treatment for the pseudomyxoma peritonei until four years after the initial diagnosis, by which point it had progressed considerably.

During the investigation, we took independent medical advice on Mr A's care and treatment from two consultants in colorectal surgery, one of whom has extensive experience in the treatment of pseudomyxoma peritonei.  We found that the delay in Mr A receiving treatment was largely due to a failure to review a scan that was carried out and make further appointments to monitor Mr A's condition.  However, we also found that there was a failure of board staff to discuss Mr A's case at a multi-disciplinary meeting when he was first diagnosed, and to discuss Mr A's case with a specialist pseudomyxoma peritonei unit.  We further found that there was a failure of the responsible consultant to communicate with Mr A and his GP regarding the diagnosis.

Mrs C also complained about the handling of her and Mr A's complaints.  Mr A's first complaint to the board did not receive a response.  When Mrs C later made a complaint, it did not receive a response for over a year, and Mrs C had to regularly contact the board for updates as they were not keeping her informed of progress.  The final response that Mrs C received was a copy of an investigation that had been carried out into Mr A's care, and did not address all of the issues raised in the complaint, apologise to Mrs C and Mr A for failings identified, or give information as to remedial action taken or proposed.  Additionally, details of how to contact the SPSO were not given to Mrs C.  I considered the large number of failings in basic and fundamental complaints handling principles to be unreasonable.

Redress and recommendations
The Ombudsman recommends that the Board:

• apologise to Mrs C for the failings identified in complaint (a) in relation to the delay in treatment for Mr A's pseudomyxoma peritonei;
• provide evidence that MDT meetings are being held to discuss this type of cancer in line with their standards;
• review their processes for ensuring that scan results are reviewed and followed up, and ensure that current processes are sufficient to avoid a repeat of the failings identified by this investigation;
• consider implementing a policy to discuss the treatment options for all cases of proven or suspected pseudomyxoma peritonei with a specialist unit;
• draw the comments of Adviser 1 regarding communication of diagnoses to patients and GPs to the attention of the relevant consultant;
• apologise to Mrs C for the failings in complaints handling identified by this investigation;
• remind the relevant staff that formal complaints should be passed on to the complaints department; and
• review their handling of this complaint and identify areas for improvement.

Summary
Mr C complained on behalf of his sister (Miss A) who had amongst other things profound learning difficulties, type 2 diabetes and was blind.  He said that after falling out of bed and hurting her neck on 12 December 2015, she attended the Emergency Department (ED) of Glasgow Royal infirmary.  Although the board maintained that Miss A had been treated reasonably, Mr C said that staff did not take into account her serious disabilities when examining and treating her and she was discharged home.  Miss A's condition deteriorated and she returned to the ED where she was later given an x-ray and CT scan which showed fractures in her neck.  She was admitted to the National Spinal Injuries Unit.

We took independent advice from a consultant in emergency medicine and from a registered nurse.  We found that despite the fact that Miss A had serious and profound learning difficulties which were detailed in documentation that accompanied her to the ED, these were not properly taken into account, a senior opinion was not obtained nor were available objective assessment tools used.  Mr C's opinions were not sought to establish whether he could input into the findings of her examination.  We upheld the complaints.

Redress and recommendations
The Ombudsman recommends that the Board:

• make a formal apology to Mr C and Miss A for the shortcomings identified;
• staff involved in Miss A's care on the day concerned should be made aware of the content of this report to allow them the opportunity to reflect and also consider it at their next formal appraisal;
• apologise to Miss A (copied to Mr C) that when communicating with her, staff failed to take her learning difficulties into account;
• apologise to Mr C for not reverting to him for his assistance in this matter; and
• review their advice to staff members about treating people with disabilities to establish whether or not it is currently fit for purpose.  If it is not, they should provide updated advice and guidance.

Summary
Mrs C complained about the care and treatment her late husband (Mr C) received at Raigmore Hospital after he attended the Emergency Department (ED) by ambulance.  Despite Mr C being initially diagnosed with a chest infection, his condition deteriorated suddenly and he died the following day.  Mrs C questioned whether her husband was given appropriate treatment and complained that staff did not properly communicate with her.

When the board investigated Mrs C's complaint, they did not identify any failings in relation to the treatment provided to Mr C, although they acknowledged that staff could have communicated better with Mrs C.

We took independent advice from a consultant in emergency medicine and a consultant cardiothoracic anaesthetist.  We were concerned about significant failings the emergency medicine consultant adviser identified in relation to the treatment Mr C received whilst in the ED, including the fact that the board's local investigation of the complaint did not pick these up.  We accept that the treatment in the ED led to Mr C's abrupt and unexpected deterioration.

Whilst we found that the care provided in the Intensive Treatment Unit (ITU) was of a reasonable standard, we were critical of the communication with Mrs C about her husband's continuing deterioration.  We found that Mrs C had been waiting for a significant period of time in a side room in the ED when ITU staff were trying to contact her and that this was likely the result of poor documentation and communication by ED staff.

Redress and Recommendations
The Ombudsman recommends that the Board:

• conduct a Significant Event Analysis (SEA) into the care Mr C received in the ED in order to identify appropriate improvements in clinical practice and share these findings with the family and my office;
• ensure that the findings of this investigation and the outcome of the SEA are shared with the doctors involved in Mr C's care in the ED and discussed at their next appraisal for shared learning and improvement in clinical practice;
• conduct a review of the complaint in order to explore how the complaints handling failed to identify these issues;
• provide documentary evidence showing the steps that have been taken to improve triage record-keeping;
• apologise to Mrs C and the family for the failings this investigation has identified; and
• share these findings with relevant staff who had been involved in Mr C's care to highlight the importance of documenting conversations with relatives to ensure effective communication between hospital wards.

Summary
Mrs C complained via an advocacy service in relation to her husband (Mr A) who was receiving end of life care at home.  Mrs C had gone out one morning, expecting a visit from a district nurse (the nurse) to take place in her absence.  When Mrs C returned, she found Mr A deceased and in an inappropriate position.  Mrs C called her immediate family who lived within walking distance.  Her daughter (Mrs B) covered Mr A up and the family contacted the emergency services.

Paramedics attended and confirmed that Mr A had died.  A doctor from the family's GP practice attended to certify death.  Mrs C complained to the board shortly afterwards, saying that she believed the nurse had left the property whilst Mr A was dying or after he was dead.

In response to the complaint the board conducted an internal investigation.  They interviewed Mrs C, the nurse and other health professionals involved in the case.  The nurse accepted that they had left the property without recording their visit properly, but stated they had intended to return.  They denied strongly having left Mr A in an inappropriate condition.

The finding of the internal investigation was that the nurse's version of events was confused and contradictory.  It concluded the nurse had breached professional guidelines in terms of record-keeping and that the care they had provided had fallen below an acceptable standard.

The internal investigation recommended a disciplinary hearing be held.  Mrs C's advocate advised us that the family had not been kept informed of the board's actions.  The advocate said there had been an extended and unexplained delay in the investigation and when a formal complaint was made about this, the board's complaint response was entirely inadequate.

The advocate said the family were told they could not be given any details of what had happened to Mr A, though they were told the board were satisfied that the nurse had responsibility for the condition Mr A was found in.  We reviewed all the interviews and information considered by the board's internal investigation.  We also interviewed Mrs B, who said she felt she had been overlooked by the board's original investigation.  We took professional advice on the standard of nursing care provided to Mr A and whether this met the professional standard expected of a nurse.  We found that although it was not possible to determine exactly what took place, the likelihood was that the nurse performed some form of treatment on Mr A.

There was no suggestion this had contributed to his death, but the weight of the evidence pointed to Mr A being left in an inappropriate condition by the nurse.  We found the board's investigation had failed to interview family members, and that the board had not provided the family with an adequate explanation for their actions.  The advice we received was that the nurse's actions fell below acceptable professional standards and that the care provided to Mr A was unreasonable.

Redress and recommendations
The Ombudsman recommends that the Board:

• consider a referral to the Nursing and Midwifery Council, in view of the concerns raised over the Nurse's conduct and that an explanation for any decision reached is provided to this office;
• review the procedures for the management of lone working in the community to ensure an adequate level of communication is sustained between staff and managers;
• remind staff of the importance of giving consideration to interviewing all individuals involved in an the incident under investigation;
• provide evidence that the actions identified in their review of the handling of Mrs C's complaint have been implemented;
• provide evidence that all staff have been reminded of the need to identify and record complaints accurately; and
• apologise unreservedly for the failings identified in this report.

Summary
Mrs C complained about the care and treatment given to her young son (Master A) when he attended a hospital Emergency Department (ED) over a period of two days after he suffered a head injury at nursery.  Master A has hydrocephalus and had had a shunt fitted a few months after he was born to relieve the pressure caused by fluid accumulation.  Because of this, Mrs C said that as well as the usual checks and examination, he should also have been given a precautionary CT scan.  He was not and was discharged home.

A month later, Master A and his family went abroad on holiday and he became very ill and was taken to hospital.  A CT scan taken there showed that his shunt had become dislodged and he had suffered a bleed.  He remained in hospital for four days before being returned home.

Mrs A complained to the board who took the view that the care and treatment given to Master A on the two occasions he attended the ED was reasonable.  Our investigation showed that Master A's examination in the ED had been good, specific and relevant.  However, as he had attended again for the same problem within a short time, caution needed to be taken; on the second occasion his head injury should have been discussed with a senior member of staff and as there was reason to question a shunt malfunction, staff should have had a low threshold of suspicion and considered a CT head scan.  Alternatively, as his parents felt that Master A's condition had not returned to normal, he should at least have been admitted for observation.  For these reasons, we upheld the complaint.

Redress and recommendations
The Ombudsman recommends that the Board:

• make Mrs C a formal apology recognising the identified shortcomings identified in this report; and
• ensure that the clinical staff involved in Master A's case make themselves fully aware of the relevant Scottish Intercollegiate Guidelines Network guidance ('Early management of children with a head injury', May 2009) to ensure that the same situation does not recur.

Summary
Mr C complained to us that the board had failed to provide his wife (Ms C) with appropriate clinical treatment following a GP referral to Perth Royal Infirmary for a suspected brain aneurysm.  Ms C had been referred to the hospital by a GP after becoming unwell.  In the referral letter, the GP referred to, amongst other things, a suspected subarachnoid haemorrhage (an uncommon type of stroke caused by bleeding on the surface of the brain).  Ms C had reported sudden onset of pain in her head and neck with some visual disturbance.  She was admitted directly to the acute medical unit in the hospital where she was medically assessed by a specialist trainee doctor.  She was then reviewed by a consultant physician.  She was subsequently discharged home with the problem felt to be musculoskeletal.

Ms C attended her GP on several occasions over the next few weeks.  She then collapsed at home and was taken to the intensive care unit with signs of acute subdural haematoma (a serious condition where blood collects between the skull and the surface of the brain).  Further treatment was not deemed appropriate and Ms C died in the hospital two days later.

We took independent advice on Mr C's complaint from a consultant physician.  The adviser noted that there were sufficient features to suggest that Ms C had a thunderclap headache and that a CT scan should have been performed at that time.  If this was negative, a lumbar puncture (a medical procedure where a needle is inserted into the lower part of the spine to test for conditions affecting the brain, spinal cord or other parts of the nervous system) should have then been performed and, if positive for subarachnoid haemorrhage, a neurological opinion would have been essential at that point.

We found that it was unreasonable that Ms C had been diagnosed with musculoskeletal neck pain.  The adviser said that a patient with no previous significant headache history who presents with sudden severe neck and occipital pain (pain at the back of the head) should be investigated as a thunderclap headache.  We also found that Ms C had not been monitored appropriately in the acute medical unit.

In view of the fact that Ms C's headache was not reasonably investigated, we upheld Mr C's complaint that the board failed to provide Ms C with appropriate clinical treatment on 7 January 2016.  Whilst we cannot say that Ms C's life would definitely have been saved if these tests had been carried out, the adviser has stated that it was probable that Ms C's condition was treatable.

Mr C also complained that the board had failed to address his complaint in a timely and professional manner.  We found that the board's response had not addressed all of the points Mr C had raised and that they should have provided a more detailed response to him in relation to his questions about the failure to take action in line with the relevant medical guidance.  The board also delayed in issuing the minutes to Mr C after meeting him to discuss the matter.  In view of these failings, we also upheld this aspect of Mr C's complaint.

Redress and Recommendations
The Ombudsman recommends that the Board:

• issue a written apology to Mr C for the failure to provide reasonable treatment to Ms C when she attended the Hospital on 7 January 2016;
• provide evidence that steps have been taken in the Hospital to ensure that adult patients presenting with headache are investigated in line with SIGN 107 (the Scottish Intercollegiate Guidelines Network guidance on the Diagnosis and Management of Headache in Adults);
• provide evidence that steps have been taken in the Hospital to ensure that patients are monitored appropriately;
• provide evidence that steps have been taken in the Hospital to ensure that, in appropriate cases, patients are issued with a discharge note in line with SIGN 128 (the SIGN discharge document);
• confirm that this report will be discussed at the Consultant's next appraisal; and
• issue a written apology to Mr C for the failure to provide a satisfactory response to his complaints.