Health

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mr B) about the care and treatment provided to Mr B's late wife (Mrs  A) when she was an in-patient at Queen Elizabeth University Hospital.

We took independent advice from a consultant physician. We found that, on one occasion, Mrs A was not given her dose of insulin, and that the reasons for this were not clear. We found that this resulted in Mrs A developing diabetic ketoacidosis (DKA – a potentially life threatening complication of diabetes, which happens when the body starts running out of insulin), and that there was a delay in the DKA protocol being commenced. We also found that there was a failure in communication between medical and nursing staff around the plan to measure Mrs A's blood pressure. There were also inconsistencies in recording Mrs A's intolerance to certain medication. We found that Mrs A was prescribed a medication which she had an intolerance to without the rationale for this decision being recorded.

We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr B for failing to provide reasonable care and treatment to Mrs A with regards to administration of insulin, the delay in DKA protocol being commenced and the poor management of medication. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Staff should be aware of the importance of insulin in patients with Type 1 diabetes. Diabetes medication should be given when required, and reasons for not doing this should be clearly documented.
• The DKA protocol should be commenced within the appropriate timeframe wherever possible.
• There should be one clear way for communicating tasks and results between staff groups. This should include a way for medical staff to remember what investigations and instructions they are awaiting the results of.
• Allergy/intolerance information should be recorded consistently.
• If medication is to be prescribed despite a recorded allergy/intolerance, the reasons for this should be documented.

Summary

Mr C, who is an MSP, complained on behalf of his constituent (Mr B). Mr C complained that the board failed to take reasonable care of Mr B's wife (Mrs A)'s clothing when she was a patient at Royal Alexandra Hospital, and that this resulted in Mrs A's clothing going missing. Mr C also complained that the board did not handle Mr B's claim to be reimbursed for the loss of Mrs A's clothing in line with their own policy.

We took independent advice from a nursing adviser. We found that nursing staff were not responsible for washing patients' clothing. We also found that ward staff were not responsible for marking patients' clothing, and we did not find any evidence that staff said that they would mark Mrs A's clothing as hers. Therefore, we did not find evidence that the board had failed to take reasonable care of Mrs  A's clothing, and we did not uphold this aspect of the complaint.

Regarding Mr B's claim for reimbursement, we found that the claim was handled in line with the board's policy and guidance.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Ms A) about the care Ms A received at the Vale of Leven Hospital.

Ms A was injured at work and afterwards her knee was painful and giving way. She was referred for an arthroscopy (keyhole joint surgery). Ms A was told that she had torn her anterior cruciate ligament (a band of connective tissue that holds the knee bones together and helps stabilise the joint). She was referred for physiotherapy but she continued to have problems with her knee. She was then offered surgery to reconstruct her anterior cruciate ligament, which she declined. Several years later, Ms A had a further knee arthroscopy. She was told that her anterior cruciate ligament was present, intact and functional. Ms C complained that following her first arthroscopy, Ms A was misdiagnosed with a torn anterior cruciate ligament.

We took independent advice from a consultant orthopaedic surgeon with a special interest in knee surgery. We found that Ms A had suffered a partial tear to her anterior cruciate ligament and as a result of this injury, her anterior cruciate ligament was not stabilising her knee so it required treatment. We found that Ms  A was correctly referred for physiotherapy and as this was not successful, surgery was appropriately discussed with her. We noted that the findings of her second arthroscopy were broadly similar to the first arthroscopy, as it also found evidence she had experienced a partial tear to her anterior cruciate ligament. We found that although Ms A no longer appeared to have instability in her knee joint, this may have been because of the osteoarthritis (chronic breakdown of cartilage in the joints leading to stiffness) in her knee joint. We found no evidence that Ms  A's injury had originally been misdiagnosed and, therefore, we did not uphold Ms C's complaint. However, we noted that Ms A should have been referred to a specialist to assess if anterior cruciate ligament surgery was appropriate for her and made a recommendation in light of this finding.

Recommendations

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

• Patients with anterior cruciate ligament injuries should be appropriately referred to a specialist surgeon.

Summary

Ms C complained about the care and treatment she received at Queen Elizabeth University Hospital. Ms C attended a follow-up orthopaedic (the branch of medicine involving the musculoskeletal system) clinic at the hospital after hip surgery and explained she was experiencing discomfort in her ankle. She was found to have deep vein thrombosis (DVT, a blood clot in a vein) in her calf. However, other tests also showed that she may have secondary liver cancer. It was later found that she had primary breast cancer which had spread to her liver. Ms C complained about the way she was told about her diagnosis and that she was given inconsistent information about her illness. She also complained that her care was not appropriately personalised for her.

We took independent advice from consultants in acute medicine and clinical oncology (cancer treatment). We found that the doctor who told Ms C about her diagnosis had made a conscious decision to wait overnight before giving her the details because they wanted the opportunity to discuss the matter first with the breast cancer team. While we considered that this was a reasonable approach, when Ms C was told the following day, she was alone. This does not follow Scottish Cancer guidelines and Ms C appeared not to have been appropriately supported. Therefore, we upheld this aspect of Ms C's complaint. However, we did not find that Ms C had been given inconsistent information and we found that staff had adapted her care, as far as possible, to suit her needs. Therefore, we did not uphold these aspects of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to support her properly when giving her bad news. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Patients should be adequately supported when being given bad news and discussions with patients/relatives should be fully documented in medical records.

Summary

Mr C complained about the care and treatment he received at New Victoria Hospital. Mr C had been experiencing ongoing and worsening pain in his hip region and considered that there was an unreasonable delay in treating the cause of this pain.

We took independent medical advice from a consultant orthopaedic surgeon (a  surgeon who diagnoses and treats a wide range of conditions of the musculoskeletal system).

We found that appropriate investigations were carried out to find the cause of Mr  C's hip pain but the cause of his hip pain was still unclear following these. Mr  C was referred for physiotherapy to see if that improved his condition. However, there was an unreasonable delay in offering Mr C a physiotherapy appointment. This was due to an error in the referral process, as the referral was not received by physiotherapy. We considered this delay to be unreasonable and upheld Mr C's complaint. However, we noted that the board had acknowledged and apologised for this delay.

Recommendations

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

• There should be an appropriate process in place between orthopaedics and physiotherapy to ensure that referrals are received.

Summary

Ms C complained about the care and treatment her late mother (Mrs A) received at Beatson West of Scotland Cancer Centre for metastatic breast cancer. Ms C raised concerns that there were delays between scans and treatment for Mrs A, and in particular that there was a lack of urgency when Mrs A's kidneys were failing.

We took independent advice from an oncology consultant (a specialist in the study and treatment of tumours). We found that whilst overall the scans and treatment for Mrs A's cancer were reasonable, when Mrs A's worsening kidney function was noted in a scan there was a delay in referring her to urology (the  branch of medicine and physiology concerned with the function and disorders of the urinary system). The referral was then lost which the board acknowledged and apologised for. However, they did not explain what action they had taken to prevent this reoccurring in the future, therefore, we made a recommendation on this matter. We also found that when a scan showed that there was disease progression, this should have been escalated to Mrs A's consultant in a more timely manner to allow a discussion regarding stopping Mrs  A's treatment to happen more quickly. We considered the care and treatment provided to Mrs A was unreasonable and upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the delay in referring Mrs A to urology and that the results of the scan which showed disease progression were not escalated to the consultant more promptly. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets- and-guidance.

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

• There should be a policy for escalating significant findings of investigations, in particular scans, to the relevant team or on call team in order to ensure that any required actions regarding these findings are not delayed until a patient attends clinic.
• There should be a system in place to ensure that referrals to urology are acknowledged and acted upon to prevent the situation of a referral letter going missing or not being acted upon.
• Patients with disease progression should have their results escalated to the consultant caring for them as quickly as possible to enable any discussion regarding stopping of treatment and switching to best supportive care to take place as soon as possible.

Summary

Mr C complained about the medical treatment which his late friend (Mr A) received when a request was made for the out-of-hours (OOH) service GP to call at the house and assess Mr A. Mr C said that the OOH GP examined Mr A and decided that he should be admitted to hospital. However, they did not request an immediate ambulance and ordered another ambulance to arrive within a two hour timeframe. Mr C complained that the OOH service failed to appropriately assess Mr A and failed to call for an immediate ambulance.

We took independent medical advice from a GP. We found that the OOH GP had carried out a thorough assessment based on Mr A's medical history and his presenting symptoms. It was reasonable for them to arrive at a working diagnosis that Mr A had an infection and that he required a hospital admission. However, there was no evidence of sepsis and we found that it was appropriate to order an ambulance to arrive within a two hour timeframe as Mr A did not meet the criteria for a 999 ambulance. We did not uphold Mr C's complaints.

Summary

Mr C complained about the clinical treatment he received at Inverclyde Royal Hospital. Specifically, that the treatment that he had to remove debris from his ear (known as microsuction) caused him to develop tinnitus (a ringing or buzzing noise in the ears) and that he should have had a hearing test before the treatment. Mr C also complained that questions which he raised at a follow-up clinic appointment were not fully responded to.

In response to the complaint, the board did not identify any failings in treatment or the communication that took place with Mr C about the questions he had raised at a follow-up appointment. The board also said that tinnitus is not a recognised complication of microsuction.

We took independent advice from a consultant ear, nose and throat surgeon. We found that the treatment Mr C received was of a reasonable standard and in accordance with ear care guidance issued by Health Improvement Scotland. In addition, we found that there was no requirement in terms of consent guidance issued by the General Medical Council to warn patients of the risk of tinnitus, as it is a less serious side effect that does not occur frequently with this type of procedure. We did not uphold this aspect of the complaint. However, we considered that tinnitus is a recognised risk of any noise or mechanical trauma to the ear and provided feedback to the board that they may wish to consider displaying a notice or providing a leaflet for patients in this respect.

Mr C should have received responses to the questions he had raised at his follow- up appointment. Therefore, we upheld this part of his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not responding fully to the points he raised. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Full responses should be provided to patients regarding their care and treatment, either in writing or verbally, with documentation to demonstrate what was discussed.

Summary

Mr C complained about the dental treatment he received over a number of years from a number of dentists. Mr C had recently moved to a new dental practice, where the dentist discovered that he had a blood clot in his lower jaw which had been present for some time and caused the bone to degrade. Mr C felt that the previous dentists should have discovered this at an earlier stage.

We took independent advice from a dentist. We found that there was no evidence that Mr C had reported any problems with his lower jaw, or that the lower teeth were unstable. We found that Mr C had had reasonable assessments in view of his reported symptoms over a number of consultations. We did not uphold the complaint.

Summary

Mr C made a number of complaints about an inginual hernia repair (an operation to repair a weakness in the abdominal wall) he underwent at Dr Gray's Hospital. Mr C required to have further surgery a week later to remove a testicle due to a rare but recognised complication of the surgery. Mr C complained that he had not been reasonably informed of all the recognised complications when consenting to his surgery. Mr C was also concerned that his surgery was not carried out properly, that he was discharged too soon from hospital after the inginual hernia repair, and that there was an unreasonable delay in receiving a review appointment following the operation to remove his testicle. The board apologised that they were unable to offer him a review appointment within the original planned timescale due to a high volume of patients and took action to address this problem. The board identified no other issues with Mr C's treatment. He was unhappy with this response and brought his complaint to us.

We took independent advice from a consultant general surgeon. We considered that the board's handling of the consent process was below a reasonable standard. It was not clear to what extent the term testicular atrophy (shrinkage/wasting) was explained to Mr C at the time of his clinic appointment or whether he understood this, nor was any additional patient information on the procedure provided to Mr C for reflection at this time. In addition, the consent form Mr C signed was completed on the day of surgery instead of at the out- patient clinical consultation and it did not list the possible but rare risk of testicular complication. Therefore, we upheld this aspect of Mr C's complaint.

In relation to the procedure, we considered that this was completed to a reasonable and appropriate standard. The adviser noted that the rare complication Mr C suffered was not a result of a failing in the surgery. However, we noted that the board incorrectly suggested in their response to Mr C's complaint that a consultant surgeon had performed the surgery when in fact they were supervising it to ensure the quality of the procedure. We did not uphold this aspect of Mr C's complaint but made a recommendation in light of this finding.

In relation to Mr C's discharge, we found no evidence to suggest that he was unreasonably discharged following the inguinal hernia repair. We did not uphold this aspect of Mr C's complaint.

Finally, we found that given the distressing complication Mr C experienced following his surgery, it was unreasonable for him to wait over 26 weeks to be reviewed following removal of his testicle rather than within the planned six to eight weeks. We upheld this aspect of Mr C's complaint but noted that the board had already taken action to address this issue.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings in the consent process and the failure to provide accurate information in relation to who had performed the surgery. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Surgeons should complete the consent process in the pre-operative clinic; ensure the risks are clearly explained to the patient, checking that the patient understands the information and that this is documented; and ensure the patients take a copy of the consent form to enable reflection. Information for patients should be available concerning inguinal hernia repair in a separate booklet that details 'the risks inherent in the procedure, however small the possibility of their occurrence, side effects and complications'.

In relation to complaints handling, we recommended:

• The board should ensure transparent and open communication with patients. In particular, the board should ensure that patients are informed about who undertook their surgery.