Health

Summary
Mr A, who had Alzheimer's disease (the most common cause of dementia), was admitted to a specialist ward at Royal Cornhill Hospital for assessment and treatment.  He had been displaying very challenging behaviour, and was no longer safe to be looked after at home.  He was sectioned under the Mental Health (Scotland) Act, and he remained in this hospital for the next ten months.  During this time his behaviour became more stable and he was transferred to a dementia assessment ward at Glen O'Dee Hospital.  This move was against the wishes of Mr A's partner and welfare power of attorney, Ms C.  Mr A died six weeks after being transferred, following a rapid deterioration in his physical condition.

Ms C raised concerns about a range of aspects of the nursing care that Mr A received in both hospitals.  In relation to his time at Royal Cornhill Hospital, she was concerned about Mr A's risk of falls and the staff response to this, his skin care, his oral health care, and provision of social activities for Mr A. She also raised concerns about communication with Mr A’s relatives, particularly with Ms C, given her position as his welfare power of attorney and his Named Person under the Mental Health (Scotland) Act.

In relation to the care and treatment Mr A had in Glen O’Dee Hospital, Ms C complained about the forms of restraint used to keep Mr A safe from falls, the lack of sufficient encouragement and assistance to mobilise him, and the impact of this on his skin care.  In relation to Mr A’s medical care, she was concerned that Mr A developed a sore throat that was not properly assessed, and this led him to stop eating and drinking.

When Ms C complained to the board, they identified no significant failings with the care and treatment given to Mr A, either in Royal Cornhill Hospital or Glen O’Dee Hospital.

During my investigation I sought advice from a psychiatric nursing adviser and a psychiatric adviser, who both identified failings in Mr A’s care and treatment.

This case has raised significant failings, particularly in the most standard elements of nursing care: effective care planning; keeping a patient safe; monitoring their condition; providing appropriate food and nutrition; record-keeping; and communication with relatives.  Caring for Mr A was not always made easy by Mr A’s challenging behaviour, but the planning and communication around his care were all the more necessary because of his behaviour and incapacities.  I am also particularly critical of the way the board handled this complaint and their lack of focus on their failings and ways to improve their services.  I upheld all Ms C’s complaints and made several recommendations.

Redress and recommendations
The Ombudsman recommends that the board:

• conduct a Significant Event Analysis, aimed at exploring and understanding the causes of the care failures for Mr A, in order to identify appropriate improvements in clinical practice, and explore how complaint handling failed to identify these issues;
• provide an action plan setting out improvements identified in the above Significant Event Analysis, with explanation of how they would be met, along with changes that have already taken place since these events;
• remind staff of the need to ensure that changes to visiting hours are mutually agreeable to staff, patients and relatives, and are recorded wider staff awareness;
• conduct a nursing audit in the appropriate ward to assess the current practices in relation to record-keeping, food, fluid and nutrition and vital signs monitoring;
• provide evidence that any actions identified from the nursing audit are implemented in full;
• conduct a Significant Event Analysis, aimed at exploring and understanding the causes of the care failures for Mr A, in order to identify appropriate improvements in clinical practice, and explore how complaints handling failed to identify these issues;
• draw together the findings from both Significant Event Analyses to identify any shared issues on the continuum of care and in complaints handling, to be addressed by the Board; and
• apologise to Ms C for the failings identified in this report, both in relation to Mr A's care and treatment and in relation to the responses Ms C received to her complaints.

Summary
Ms C complained about the care and treatment provided to her late daughter (Miss A) by the board's Intensive Home Treatment Team (IHTT), and about the way in which Miss A was discharged from their care.  Miss A, who had a history of low mood and self-harm, was referred to the IHTT following an attempted overdose.  She was discharged from their care after around six weeks and died at home a week later, having completed suicide.

Ms C complained about a lack of continuity of care, noting in particular the absence of a key worker for Miss A.  I took independent medical advice from a consultant psychiatrist, who noted that in a crisis service such as the IHTT, it is difficult to avoid patients being seen by a number of different staff.  However, the adviser considered that much more could have been done to enhance the continuity of care provided to Miss A.  The IHTT policy indicates that every service user will be allocated a named worker and that complex case discussions will take place, but neither appears to have happened in Miss A's case. Ms C also complained about a lack of clarity surrounding Miss A's diagnosis. I was advised that the sharing of Miss A's diagnosis was reasonably consistent throughout, although differing terminology was used.  However, I noted that there was some ongoing uncertainty surrounding the extent of Miss A's unstable personality traits, which might have benefited from a psychological opinion.  The IHTT policy indicates that a psychological opinion can be sought within the IHTT but I found no evidence of this having been considered.  I was also advised that the IHTT policy might benefit from being updated to define clearly the role of medical staff in diagnosing patients.  I upheld this complaint.

Ms C complained about the appropriateness of Miss A's discharge from the IHTT, noting that she had ongoing suicidal thoughts.  I was advised that the decision to discharge Miss A was not in itself unreasonable, as the IHTT provide short-term input to patients in crisis and that chronic risk over the long-term is not managed in this setting.  However, I was advised that the process followed in discharging Miss A was unreasonable.  I found little evidence of discharge planning and no indication that plans were discussed with Miss A.  I was particularly concerned that there was a lack of evidence of medical input into Miss A's discharge. Ms C also expressed unhappiness with the follow-up plan that was put in place and said that Miss A felt lost and abandoned.  I agreed that the follow-up arrangements were not sufficiently robust.  Miss A was discharged into the care of her GP, with the noted involvement of a private counsellor she was seeing and the provision of crisis service contacts.  I concluded that Miss A should have been referred for psychiatric follow-up.  I was concerned that Miss A was discharged entirely from the board's care on the basis of her private counselling, when no steps were taken to contact the private counsellor to find out what was being offered in terms of follow-up.  I upheld this complaint.

Miss A attended A&E on three occasions while under the care of the IHTT, following further suicide attempts.  Ms C complained that during these attendances, Miss A was not afforded sufficient privacy and dignity in her distressed states.  She also complained that there was a four hour delay in Miss A receiving a mental health assessment and did not consider that enough had been done to ensure Miss A was supported following discharge from A&E.

I took independent medical advice from a consultant in emergency medicine.  I was advised that Miss A had been treated in line with normal practice in a busy A&E department and I could not conclude that there was a failure to afford her adequate privacy or dignity.  I was advised that a four hour wait is not unreasonable where a patient has taken an overdose and a detailed medical assessment is required prior to mental health assessment.  I was critical, however, that it was not documented who was accompanying Miss A and assuming responsibility for her when she was discharged following her third attendance.  In addition, I was advised that a mental health assessment form was only completed for Miss A's first attendance.  While I was assured that she was appropriately assessed, and that this omission made no material difference to the care she received, I concluded that it would be good practice for this form to be completed in every instance.  On balance I did not uphold this complaint but I made some recommendations.

Redress and recommendations
The Ombudsman recommends that the board:

• support the IHTT to implement and adhere to the IHTT Operational Policy, specifically with regard to named workers and facilitating complex case discussions;
• consider revising the IHTT Operational Policy to include a description of the roles of medical staff (including different grades of medical staff) within the IHTT;
• apologise to Ms C for the failings identified in the care and treatment provided to Miss A;
• review the discharge planning process in the IHTT, taking account of the considerations highlighted in this report;
• review the IHTT Operational Policy, setting out clear guidance for when patients should be seen by medical staff;
• provide detailed evidence of all action taken to implement the AER (adverse event review) recommendations;
• apologise to Ms C for the identified failings in the process for discharging Miss A and planning her follow-up care;
• consider introducing a system whereby completion of the A&E mental health risk assessment form is mandatory for all mental health patients; and
• highlight to A&E staff that it is good practice for them to document who vulnerable patients are accompanied by on discharge, and whether the accompanying persons are happy to accept responsibility for patient safety.

Summary
Mrs A complained about the care and treatment she received from the board. Mrs A died before I completed my investigations and so her complaint was taken on by her daughter (Mrs C).

Mrs A attended University Hospital Crosshouse. She was told that she may need a heart valve replacement but that before this could go ahead, she would need to undergo a cardiac angiogram (a type of x-ray used to examine blood vessels), which is an invasive procedure.  Mrs A gave consent and underwent an angiogram in a second hospital run by the board.  Mrs A said that she experienced pain during the procedure and asked for it to be stopped.  The procedure continued but Mrs A did not recover well and while no abnormality was obvious, her condition did not improve.  Mrs A's level of consciousness declined and a few days later she was noted to have lost power in her lower limbs.  A scan of her spine showed evidence of an ischaemic event (like a stroke) within her spinal cord.

Mrs A was transferred to a third hospital (in a different NHS board), where her scan was reviewed.  This showed the appearance of a stroke on the surface of the brain. Mrs A did not recover the use of her lower limbs.

Mrs A complained that she had not been warned of the possible risks associated with an angiogram.  She also complained of an unreasonable delay in confirming a stroke and that as a result her treatment was delayed.

The board said that Mrs A had made informed consent for the procedure and  recognised that there had been a delay in diagnosis.  They added that even if a stroke had been confirmed sooner, it was unlikely there would have been a different outcome regarding surgery or spinal cord recovery.

I took independent advice from a consultant cardiologist and from a consultant neuroradiologist (a specialist in the analysis of injuries of the brain). The advisers found no evidence that all the risks and benefits of an angiogram had been discussed with Mrs A, including that bleeding and vascular damage that could cause a possible stroke or heart attack are a recognised complication.  I also found the board's consent forms and printed information to have been inadequate.  I established that there was an error in interpreting Mrs A's scan and that her diagnosis had been delayed, although Mrs A's treatment and outcome were likely to have been the same had an earlier diagnosis been made. I therefore upheld the complaint.

Redress and recommendations
The Ombudsman recommends that the Board:

• make a formal apology to Mrs C for their failure to consent Mrs A properly;
• review their consenting procedure and update it in accordance with General Medical Council guidelines.  They should demonstrate to me that they have done so;
• review their relevant information booklet/sheet to ensure that they reflect the appropriate guidelines; and
• apologise to Mrs C for the delay in Mrs A's diagnosis.

Summary
Mrs C's husband (Mr A) had been diagnosed with lung cancer and discharged to the care of his medical practice.  To help manage Mr A's pain at the end of his life, Mrs C was allowed to administer a controlled drug.  Despite this arrangement, Mrs C said that the practice failed to manage Mr A's pain reasonably and to make reasonable arrangements to ensure a sufficient amount of pain relief was available.  Mrs C also said that the practice failed to communicate with her in a reasonable way about administering pain relief and to keep accurate records.  Mrs C said that as a result of this, Mr A suffered intolerable pain before his death, which caused her extreme distress.

I took independent advice from a GP adviser.  The adviser considered that in relation to treatment decisions and pain management, the standard of care and treatment provided was reasonable.  Moreover, while there were administrative shortcomings in relation to record-keeping, these were not significant and had no detrimental clinical effect on Mr A's care.  I accepted that advice. With regard to the governance arrangements in relation to Mrs C's administration of the medication,  I found that there was effectively an informal arrangement between the practice and Mrs C which allowed Mrs C to administer a controlled drug without the practice first putting adequate safeguards in place or seeking guidance from a specialist.  I agreed with the adviser that it was of concern that GPs continued to prescribe a controlled drug after expressing concerns that Mrs C had administered the medication without clinical advice.  Furthermore, the practice failed to ensure that Mr A consented to the arrangement. I upheld this part of Mrs C's complaint and made recommendations.

Mrs C also said that the practice did not respond reasonably to her complaints. I found that the practice's handling of Mrs C's complaints was reasonable and so did not uphold this complaint.

Redress and recommendations
The Ombudsman recommends that the practice:

• ensure the GPs who instructed Mrs C in relation to breakthrough medication and the other GPs who subsequently issued prescriptions for oxycodone seek support from the board's clinical support group, in relation to responsibilities for prescribing and consent under GMC (General Medical Council) guidance;
• ensure the relevant GPs discuss the findings of this investigation at their annual appraisal;
• ensure the relevant GPs familiarise themselves with the GMC guidance as a priority;
• draft a protocol in conjunction with the board to support patients and/or carers to administer prescribed subcutaneous medication by injections; and
• apologise for the failings this investigation identified.

Summary
Mr A, who suffered from schizophrenia (a long-term mental health condition that causes a range of different psychological symptoms), was admitted to the Clinical Assessment Unit (CAU) at Forth Valley Royal Hospital (the hospital).  Mr A had been suffering from a sore throat, a cough and a wheeze in his chest.

Mr A was treated for an infection and the possibility was raised that he may have chronic obstructive pulmonary disease (COPD, a disease of the lungs in which the airways become narrowed).  The day after his admittance, Mr A was reviewed and was transferred to a medical ward.  Mr A died the following morning.

Mr A's mother (Mrs C) complained that Mr A did not receive reasonable care and treatment and that the board failed to take into account his lack of capacity to understand how ill he was.  She also complained that the standard of record-keeping was not adequate and that she was not able to obtain accurate information from staff about what had happened to her son.  In addition, she complained that she was given unclear information about whether a SAE (significant adverse event) investigation by the board into Mr A's death would be carried out.

As part of my investigation, I obtained independent advice from a senior doctor with experience in acute medicine (adviser 1) and a nursing adviser (adviser 2). I also considered the board's own investigation of the complaint.

The board acknowledged that it was unacceptable that Mr A's observations were not carried out four hourly after his transfer to the medical ward and apologised for this failing.  However , adviser 1 said that there were failings in relation to Mr A's care and treatment throughout his admission to the hospital.  Adviser 1 said that in a patient with type 2 respiratory failure (which Mr A had), the measurement of arterial blood gases (ABGs) to provide information regarding the amount of carbon dioxide in the blood stream and the acid-base status of the patient was important.  Adviser 1 said that Mr A's ABGs should have been rechecked and despite the deterioration in the ABGs there was no plan or comment in the medical records.  In addition, Mr A was not reviewed by a consultant from the respiratory team.

Adviser 1 added that, while it was reasonable that Mr A received treatment for an exacerbation of COPD, other diagnoses should have been considered and treatment for this should have been part of Mr A's management plan.

While the board said that Mr A was deemed to be in a stable position, adviser 1 said that on admission and throughout his admission to hospital he was significantly unwell.

Adviser 2 also indicated that the nursing care Mr A received fell below the standard expected of a patient with a recognised respiratory condition.

I was concerned that, given Mr A's past medical history and in view of his refusal of treatment during his admission to the hospital and that he left the hospital against medical advice, a formal assessment of his mental capacity to understand the seriousness of his illness and ability to make informed decisions was not carried out.

Both advisers said that there was a lack of recognition of the seriousness of Mr A's condition by nursing and medical staff. They said he was not seen by a consultant until over 24 hours after his admission and was not seen again by a senior clinician prior to his death.  I am critical of the failings which meant, that potentially, the opportunity to recognise and treat Mr A was missed.

The board also accepted that there were failings in relation to record-keeping and had taken action as a result of these failings.  However, I am concerned that there appear to be conflicting reports of how Mr A spent his final hours. I consider that this would have added to Mrs C’s and the family’s distress at a very difficult time. I am also concerned that the advice I received, and accept, is that the lack of prescription of oxygen on Mr A's chart was not in accordance with guidance and that the miscalculation which occurred in relation to the national early warning score (NEWS) was in the view of adviser 1 a serious issue.

While the board explained why they decided that an SAE investigation would not be carried out, adviser 1 said that in this case there were issues around the recognition of an acutely ill patient, assessment of mental capacity and escalation and treatment of Mr A's type 2 respiratory failure and that an SAE investigation should have taken place.  Adviser 1 was of the view that there were serious lessons to be learned from this case which needed to be acted on by the board.

Redress and recommendations
The Ombudsman recommends that the board:

• apologise for the failings identified in this complaint;
• bring adviser 1's comments about the frequency of the ABG measurements to the attention of relevant staff and report back on action taken;
• take steps to ensure that, when patients with a known history of mental health problems are formally assessed for capacity, a recognised clinical assessment instrument is used, or alternatively an opinion is sought from the psychiatry service;
• take steps to ensure all patients admitted acutely are reviewed within the timeframe recommended by the Royal College of Physicians;
• take steps to ensure that timely escalation of acutely unwell patients with acidotic type 2 respiratory failure occurs and they are reviewed in person by either a respiratory physician or other clinician with appropriate knowledge and experience;
• bring the failures identified in relation to Mr A's prescription chart and the miscalculation of the NEWS to the attention of relevant staff and ensure they are addressed as part of their annual appraisal;
• carry out an audit of NEWS charts to ensure the documentation is accurate and report back to this office;
• consider the current education and training in place for the care of vulnerable adults in acute care and take any appropriate steps to meet any gaps identified and report back on action taken;
• provide a copy of the completed nursing review referred to at paragraph 43;
• in view of adviser 1's comments, carry out a reflective SAE investigation of this case and provide this office with a copy; and
• review their current significant adverse incident guidance in light of adviser's 1's comments detailed in this report.

Summary
Mr C, who suffered from a hereditary heart condition, had an operation at the Royal Infirmary of Edinburgh to remove a machine implanted in his chest to monitor his heart.  The operation was carried out by a trainee doctor. When the trainee doctor encountered difficulties, he was assisted by a more senior trainee doctor.  Mr C subsequently required a second operation to revise the scar the first procedure had left on his chest.

In investigating, I took independent medical advice from a consultant cardiologist, as well as considering the board's own investigation of the complaint.

Mr C complained the first operation had not been carried out to an appropriate standard.  He said that the experience had been painful and distressing and  believed the correct procedures had not been followed. Mr C believed the trainee doctor performing the surgery had not been competent to do so, noting that the time taken to perform the operation meant he required additional anaesthesia, as his initial dose had worn off.

The board said they had thoroughly reviewed Mr C's treatment. The board said the tools for cauterising the wound to stop bleeding post-surgery had not been available.  Silk stitches had been used instead, but these may have contributed to the poor healing Mr C experienced. The board said the consultant responsible for supervising the operation was available, but had not been present throughout the operation.  The board acknowledged Mr C's experience fell short of what he could have expected.

The adviser said the board had not adequately explored the conflict between the contemporaneous note of the operation and the conclusions reached by the complaint investigation.  The operation note stated cauterisation had been used to stop Mr C's bleeding, but as the complaint investigation acknowledged, this could not have been performed as the equipment was not available at the time.  The adviser said the operation note's inaccuracy had not been properly explored, nor did the note record the difficulties encountered during the surgery. The adviser said it was unreasonable for a trainee doctor to be allowed to perform the surgery unsupervised, as it was not a straightforward procedure.

The adviser added the board did not address the issue of supervision.  Their complaint response gave the impression a consultant had been present at points during the operation.  The available evidence showed no consultant had been present at any point, nor had they been aware Mr C's procedure was being carried out by a trainee doctor.  The adviser also noted Mr C's consent was not properly obtained and that there were inadequate records of the information provided to him prior to surgery.

I found the board failed to investigate Mr C's complaint thoroughly, although they had accepted the standard of treatment received was unacceptable.  I also found they had failed to deal comprehensively with the service failures Mr C experienced.  I am critical of these failings, which resulted in a misleading formal response being provided by the Board and a lack of evidence that adequate steps had been taken to prevent a reoccurrence.

Mr C also complained that the effect of the first operation had not been recognised by the board.  He had stated to the board that his business had suffered severely whilst he was unable to work and that he had been forced to cease trading.  I was critical of the board for failing to address this issue, even though Mr C raised it twice during his complaint.  I considered the board had to address the impact on him of the failure to carry out his surgery in a reasonable fashion.

Redress and recommendations
The Ombudsman recommends that the Board:

• provide evidence of the actions taken by Doctor 2 to improve their skills and their subsequent appraisals;
• provide evidence that Doctor 2 has continued to practice without significant subsequent complaints or concerns being raised;
• provide evidence that their policy for the supervision of trainees during surgical procedures has been reviewed;
• review the consent forms used for this type of surgery to ensure they accurately reflect the potential complications;
• remind all staff of the importance of documenting consent fully and accurately; and
• provide Mr C with a comprehensive and patient centred response to the issues he has raised concerning the impact of the surgeries on his ability to work and his finances.

Summary
Mr C had a hip replacement operation at Raigmore Hospital.  During the operation, he was aware that the first attempt to insert the implant into his hip had not been successful, and the surgeon had tried again.  This had prolonged the time he was in theatre, and, given the length of time the operation was taking, Mr C had asked for further anaesthesia for the pain.  He found the experience to be very distressing and complained that the board had not provided him with a reasonable standard of care.

I took independent advice from two advisers; one a consultant in orthopaedic surgery (adviser 1) and the other a consultant anaesthetist (adviser 2).  Whilst there were some difficulties during the procedure, of which there is more detail in my full report below, adviser 1 considered that the standard of surgery was reasonable.  However, adviser 2 reported that Mr C was uncomfortable for over an hour until the anaesthetist administered a general anaesthetic, and it would have been reasonable for this to have been undertaken earlier.  Based on this, I upheld Mr C’s complaint about the care he received in his operation.

Mr C was discharged from hospital, and he was given aspirin to take.  However, around two weeks later he was readmitted to hospital with a pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs).

There are national guidelines, issued by the Scottish Intercollegiate Guidelines Network (SIGN) and the National Institute for Health and Care Excellence (NICE), which relate to the use of treatments to prevent VTE (the formation of blood clots in the vein).  These guidelines state that aspirin is not considered an adequate treatment for reducing the risk of VTE for patients in hospitals.

The advice I received from adviser 1 is that the failure to follow the guidelines on treatment following his surgery led to a significant injustice to Mr C in that he suffered a life-threatening condition which required another admission to hospital for treatment.  The surgeon who carried out the surgery had noted in Mr C’s operation note that he should receive anticoagulant therapy but another member of staff had discharged Mr C with aspirin.  However, the surgeon had gone on to tell my complaints reviewer that it was common throughout Scotland for aspirin to be provided for patients who had undergone joint surgery, even though this is against recognised SIGN guidelines.  The board confirmed to my complaints reviewer that there was no specific board policy on this, but that if anticoagulant therapy wasn’t provided to a patient, this should be documented and explained by the clinician taking that decision.

I am very concerned not only that the relevant guidelines were not followed in Mr C’s case, but also about the board’s practice in general.  It remains unclear to me if the board have a coherent policy that is being followed within Raigmore Hospital and beyond.  As a result, an urgent review is required. I also intend to write to the Chief Medical Officer to draw their attention to my concerns about the use of aspirin and its potential implications for patient safety which have come to light in the course of my investigation.

Redress and recommendations
The Ombudsman recommends that Highland NHS Board:

• bring adviser 2’s comments in relation to anaesthesia to the attention of relevant staff;
• review as a matter of urgency the practice to ensure that its surgeons take into account the relevant guidelines on VTE prophylaxis;
• review its standard operating procedures concerning VTE prophylaxis for patients on discharge taking into account the relevant guidelines; and
• apologise to Mr C for the failures this investigation identified.

Summary
Mrs C attended the Golden Jubilee Hospital for a modified Brostrom procedure (ligament repair) on her ankle.  Following surgery, tests showed she had severe nerve damage. This was believed to have been caused by the popliteal nerve block anaesthesia (an injection of local anaesthetic near the nerves that go to the area being operated on) that she received for the surgical procedure.  Mrs C complained that she was not informed the nerve block would be carried out or about the risks. She said that she did not see the consultant anaesthetist before the procedure.  Mrs C complained that her injury was caused during the procedure and that staff failed to carry out the procedure to a reasonable standard.  She said that the nerve damage had had an enormous impact on her life.

As part of my investigation, I obtained independent advice from a medical adviser who is a consultant anaesthetist.  The adviser said there was no documented evidence in Mrs C's medical records of a discussion about the surgical procedure and its possible side effects, whether common but minor side effects, or rare but serious ones.  The adviser noted that the General Medical Council (GMC) guidance on consent issues was clear that patients must be told about recognised serious adverse outcomes, even if they are rare.  Nerve damage was a recognised side effect of techniques such as the nerve block so, even though the risk of permanent nerve damage was very rare, I considered it a failing that Mrs C was not warned about it.  The limited interaction with Mrs C before her operation meant that staff did not obtain her informed consent and I upheld her complaint.  I was concerned that these failings may have been caused by the pressures on the service.  I recommended the board conducted a review to ensure enough time was spent with patients before procedures to obtain consent properly.

Regarding Mrs C's complaint that the procedure was not carried out properly, the adviser noted that there was no record taken at the time of the procedure of the anaesthetist's technique and practice.  This was a significant failing.  However, the adviser said the technique reported later (although without much detail) gave an indication of a reasonable technique by an experienced clinician.  I agreed with the advice that there was limited documentary evidence to indicate that the practice and technique was of a reasonable standard.  Although there was no clear evidence that Mrs C's injury was caused during the procedure due to a failure by staff, the lack of contemporary record-keeping meant there was no assurance of carefully considered practice and technique.  On balance, I upheld the complaint.

Redress and recommendations
The Ombudsman recommends that the Board:

• bring the failings (related to explaining the risks of a popliteal nerve block anaesthesia) to the attention of relevant staff and ensure they are raised as part of their annual appraisal;
• review the service to ensure there is sufficient time to properly obtain (and document) consent for procedures;
• bring the record-keeping failings (related to carrying out the procedure in an appropriate manner) to the attention of relevant staff and ensure they are raised as part of their annual appraisal; and
• apologise to Mrs C for the failures my investigation identified.

Summary
Mr A, who was suffering from lung cancer, had an operation at Aberdeen Royal Infirmary to remove his lung.  During the operation, Mr A suffered from hypoxia (a deprivation of oxygen).  He was transferred to intensive care but did not regain consciousness and died one week later.  Mr A's daughter (Miss C) complained about the care and treatment provided to her father.

In investigating, I took independent medical advice from a consultant anaesthetist, as well as considering the board's own investigation of the complaint.

Miss C complained that the consultant anaesthetist failed to provide a reasonable level of care to Mr A prior to and during his surgery.  The adviser said that surgery should not have proceeded when it became apparent there was a problem with monitoring carbon dioxide levels in Mr A's blood, and that it was concerning that the consultant anaesthetist had needed advice on methods to maintain blood oxygen levels and treat hypoxia.  The adviser also noted that the board's own investigation had acknowledged shortcomings in the communication between the surgeon and the consultant anaesthetist during surgery, and that the consultant anaesthetist had not been assertive enough in their decision-making.  I considered that the performance of the consultant anaesthetist fell below the reasonable level of care from a specialist doctor who has achieved consultant grade.

Miss C also complained that her father's suitability for surgery was not appropriately assessed.  The adviser said that the tests used for Mr A were generally acknowledged to have limitations and other tests should have been considered which may have prompted more investigation ahead of surgery.  The board said that their investigations found no problems with Mr A's pre-operative assessment.  I found this to be inaccurate and I was critical of the board for failing to identify that the assessment could have been more robust and to act upon this accordingly.  I also found that the failings in the
pre-operative assessment meant that neither Mr A nor his family were able to have an informed discussion about the risks of surgery.

The board acknowledged that there were significant failures in their post-operative communication with the family.  It was obvious to staff how unwell Mr A was after his operation, but despite this, it was not until around 36 hours later that someone from the surgical team properly discussed matters with the family.  This was the most distressing part of this case.  All other issues relate to technical problems, and the difficulties of high risk surgery, but this issue relates to the basics of human kindness and interaction with a family in distress.  This contributed significantly to a breakdown in trust between Mr A's family and some medical staff.  Although the board recognised that the communication was inadequate, I was not convinced that they have taken sufficient action to ensure this does not happen again.

I upheld all of Miss C's complaints and made several recommendations.

Redress and recommendations
The Ombudsman recommends that the Board:

• provide evidence of the actions taken by the consultant anaesthetist to improve their non-technical skills and their subsequent appraisals;
• provide evidence that the consultant anaesthetist has continued to practice without significant subsequent complaints or concerns being raised;
• provide evidence that the consultant anaesthetist has revalidated with the General Medical Council, if this has been achieved as part of the five year cycle since this operation;
• review its pre-operative assessment procedure for lung cancer surgery, to ensure that cardiopulmonary exercise tests and echocardiograms are included for appropriate patients;
• review their lung cancer pre-operative assessment procedures to ensure FEV1 and the Diffusing capacity of the lung for Carbon Monoxide DLCO are calculated prior to surgery in order that post-operative lung function is taken into account;
• review their consent procedure for lung cancer surgery to ensure that it informs the patient what level of risk the operation will incur for them;
• review their procedures to include a requirement for a member of the surgical or anaesthetic team to speak to either the patient or their family at the first available opportunity following an adverse incident that requires admission to Intensive Care Unit;
• review the findings of the Anaesthetic Department Morbidity and Mortality meeting to identify if, and why medical staff declined to support the consultant anaesthetist in his meeting with the family; and
• remind staff that notes are taken of any meetings with family or patients following adverse events.

Summary
Ms C had been referred to a consultant plastic surgeon then to a consultant general surgeon to undergo a surgical procedure on her buttocks.  She has suffered from internal and peri-anal abscesses for a number of years and had previously undergone treatment to drain these on a number of occasions.  Ms C said that she had been assured that she would not suffer from any issues with continence following the operation, as this was a significant concern for her prior to undergoing surgery.  Following the operation, Ms C found that she was incontinent.  As a result she had to undergo a colostomy procedure, which has had a significant impact on her personal life, resulting in her having to give up work.

I took independent advice from a consultant colorectal surgeon, who said that incontinence was a well-recognised side-effect of the procedure Ms C had.  Ms C said that she would never have consented to the procedure had she been made aware of this risk.  I found Ms C's medical notes documented that this was an area of great concern to her, therefore I consider that it was unreasonable that this was not discussed with her and documented prior to surgery, nor did the consent form that she signed mention this as a possible risk of the surgery.

The board accepted that the forms Ms C signed had not documented incontinence as a risk of the surgery.  However, they did dispute whether Ms C was ever given an assurance that there was no risk of this complication from the procedure.  I do not accept that this removes the responsibility from the board in this regard.  Under General Medical Council guidelines, the medical staff responsible for her care had an obligation to ensure that Ms C was able to give informed consent, particularly as she had identified a particular concern before the operation.

I also found that the board failed to respond appropriately to Ms C's complaint about the cause of her incontinence.  Whilst it is possible that the incontinence is a result of a progression of Ms C's on-going condition, it is also possible that it was a result of a complication of the surgery.  Given this, the board's failure to provide adequate information to her before the procedure and later in their complaints responses was unreasonable, so I upheld the complaint.

Redress and recommendations
The Ombudsman recommends that the Board:

• review the consent forms used for this type of surgery to ensure they accurately reflect the potential complications;
• remind staff of the importance of identifying and documenting that issues of importance to patients have been discussed during the consent process; and
• apologise unreservedly to Ms C for the failings identified in this report.