Health

Summary

Mr C complained to us on behalf of his client (Mrs B) in relation to the care provided to her late husband (Mr A). Specifically, Mrs B had concerns about the end of life care Mr A received. During our investigation, Mrs B advised us she wished to withdraw the complaint and explained she was considering legal action.

Summary

Mr C complained about the care and treatment he received at Wishaw General Hospital (WGH) when he attended the emergency department after falling at home and injuring his lower back. Mr C was concerned that he was discharged home without having had an x-ray. He was also dissatisfied about the in-patient hospital care he received after being admitted to hospital two days later at which time an x-ray confirmed a spinal fracture. Mr C was unhappy about delays in transferring him to a different hospital spinal unit and being informed that he had a second spinal fracture.

We took independent advice from a consultant in emergency medicine and a consultant orthopaedic surgeon (a specialist concerned with the musculoskeletal system). In relation to the care Mr C received in the emergency department, we considered that the decision not to do an x-ray and the delay in diagnosis were reasonable given that a number of factors made this type of injury unlikely in Mr C's case. Therefore, we did not uphold this aspect of Mr C's complaint.

In relation to the orthopaedic care received, the board acknowledged that it would have been appropriate to have discussed Mr C's case again with the spinal unit of another hospital. We found that there was a lack of communication with Mr C in relation to his second fracture and that a more senior discussion with the spinal unit may have led to more timely transfer. Therefore, we upheld this aspect of Mr C's complaint. However, we noted that these issues were unlikely to have influenced his subsequent treatment.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings in communication regarding his second fracture. 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 informed of relevant test results and this should be fully documented in the medical records.

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

Summary

Mrs C complained about the care and treatment she received at Wishaw General Hospital. Following a heart attack, Mrs C attended the hospital on a number of occasions in the period whilst she waited for heart surgery. She was unhappy with the way the board managed her condition in this period and the way the board coordinated her care.

We took independent advice from an emergency medicine consultant, an acute physician and a consultant cardiologist (a doctor who specialises in finding, treating and preventing diseases of the heart and blood vessels).

Mrs C firstly raised concern that the board failed to investigate her symptoms and provide her with appropriate treatment. We found that, during the first admission, Mrs C was diagnosed with an acute coronary syndrome (symptoms attributed to obstruction of the coronary arteries). Mrs C also had hyperglycaemia (high blood glucose) but was not prescribed insulin. The adviser noted that tight blood glucose control is important in acute coronary syndrome and considered that the board failed to monitor Mrs C's blood glucose levels appropriately and failed to prescribe insulin. We also concluded that there had been a delay in Mrs C being reviewed by a cardiologist and that a GRACE score (which takes into account a patient's age, heart rate, systolic blood pressure, kidney function, signs of heart failure, as well as other parameters in order to calculate the risk of in hospital death) should have been calculated earlier as this can inform the need for angiography (a type of x-ray used to check the blood vessels). In relation to a later hospital admission, we considered that it was unreasonable for the board to have discharged Mrs C without assessment by a senior physician, in view of her medical history and presenting symptoms. We upheld this aspect of Mrs C's complaint.

Mrs C also complained that the board failed to coordinate her surgery with another NHS organisation that was involved in her care. The board acknowledged that there was a lack of detail in the documentation of the conversation between their medical staff and the staff from the other organisation. We found a number of points in Mrs C's care where the communication with the other organisation could have been better. We upheld this aspect of Mrs C's complaint.

Finally, Mrs C complained that the board failed to investigate her complaint reasonably. The board acknowledged that they had not addressed all the issues raised in her complaint letter. We considered that since Mrs C's original complaint spanned two NHS organisations, and the co-ordination and communication involved between each, the board should have worked more closely with the other organisation and issued a single complaint response. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide reasonable care and treatment; unreasonably discharging her without assessment by a senior physician; failing to coordinate her care with another board reasonably; and not fully responding to her complaint. 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:

• Where a patient presents with an acute coronary syndrome and has hyperglycaemia, close monitoring of blood glucose levels should be a routine part of acute coronary syndrome management. Insulin should be prescribed for patients who require insulin and adm
• Patients who have been diagnosed with an acute coronary syndrome should be reviewed by a cardiologist within a reasonable timescale. In line with guidelines, patients should be risk assessed for future adverse cardiovascular events and the timing of coron

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

Summary

Mr C attended the prison health service on a number of occasions with chest infections and high blood pressure. He complained that he did not receive appropriate medication and that there were delays in being referred to specialists.

We took independent advice from a GP adviser. We found that Mr C had been assessed and treated appropriately. We also considered that appropriate referrals had been made, and that the waiting times for appointments were normal. We noted that there had been a delay in discussing x-ray results with Mr C, but the board had apologised for this and had provided evidence of improvements in their recording and checking system, to prevent this from happening again.

We did not uphold this complaint.

Summary

Miss C raised a complaint about the care and treatment she had received from her dentist over an extended period of time. Miss C had suffered from pain in one of her lower teeth and was advised she would require root canal treatment. Miss C continued to be in pain; the treatment had to be repeated and also caused problems with an adjacent tooth. Miss C said she was told the tooth required extraction and was referred to the dental hospital for further treatment. Miss C was dissatisfied with the way the dentist managed her dental care.

We took independent advice from a dentist. We found that the dental treatment which Miss C received was appropriate and in accordance with usual practice. The symptoms which Miss C had reported were uncertain, therefore a period of monitoring was required. The suggestion by the dentist for root canal treatment or extraction was reasonable in view of the dental records and x-rays which were taken. We did not uphold the complaint.

Summary

Mrs C complained to us on behalf of her late sister (Ms A). Ms A had cancer and was receiving radiotherapy treatment (a treatment using high-energy radiation) in hospital. Mrs C complained that there was an unreasonable delay in providing Ms A with radiotherapy treatment and Mrs C felt that Ms A should have been prioritised due to her pain levels. Mrs C also complained that the board did not investigate her complaint reasonably.

We took independent advice from a consultant oncologist (a doctor who specialises in cancer treatment). We did not find that there was an unreasonable delay in providing Mrs A with treatment. The adviser commented that it is not routine practice to prioritise patients' scans or treatment slots based on symptoms. We also considered that the board took reasonable steps to manage Ms A's pain whilst in the hospital, as she had been provided with pain relief medication during her admission. We did not uphold this aspect of the complaint.

Regarding complaints handling, we were unable to definitively assess how accurate or inaccurate the board's response to Mrs C's complaint was as they could not provide us with evidence on Ms A's admission timings. The board, therefore, failed to demonstrate that their response to Mrs C's complaint was evidence-based and we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for not investigating her complaint reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

Summary

Mr and Mrs C complained on behalf of their daughter (Ms A) about the orthodontic treatment (a speciality field of dentistry that deals with malpositioned teeth and the jaws) she received. Ms A underwent orthodontic treatment to treat mild crowding of her teeth (when there is not enough space for all teeth to fit normally within the jaws). Four of her teeth were removed, and braces were fitted. After the braces were removed Mr and Mrs C were concerned that the treatment had changed Ms A's facial profile and affected her lip support. They believed that there had been other methods of treatment available, which they felt that the orthodontist had failed to discuss with Ms A.

We took independent advice from a dental and orthodontic adviser. We found that Ms A's overcrowding was treated appropriately and that a good result was achieved. We did not uphold the complaint about the treatment provided.

Mr and Mrs C also complained that the orthodontist failed to obtain Ms A's informed consent before proceeding with the treatment. We found that there was no evidence of a proper discussion of the problem that Ms A presented with or the expectations she had of any treatment. We also did not see any evidence of any information being given to Ms A about what treatment options were availale. We upheld this aspect of the complaint.

Finally, Mr and Mrs C complained about their way that their complaint was handled by the orthodontist. We found that the complaint had been handled appropriately and in a timely manner. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for failing to obtain valid consent to the treatment plan, with recognition of the implications of failing to obtain full consent on the choices made. The apology should meet the standards on apology 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:

• The quality of the orthodontist's clinical treatment notes should be improved. In particular, they should focus on improving the way they document orthodontic assessments, gather orthodontic records and use them to ensure that a comprehensive explanation

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

Summary

Ms C complained about the care and treatment her late father (Mr A) received at Queen Elizabeth University Hospital. Mr A was admitted to hospital with a broken hip after falling at home and underwent an operation. Ms C complained about both the medical and nursing care Mr A received. The board acknowledged that there was an unreasonable delay in transferring Mr A to the orthopaedics (the specialty of medicine regardingconditions involving the musculoskeletal system) ward and identified failings in nursing care, which they apologised to Ms C for. Ms C was unhappy with this response and brought her complaint to us.

We took independent advice from a consultant orthopaedic and trauma surgeon (a specialist in diagnosing and treating a wide range of conditions of the musculoskeletal system) and from a registered nurse. We found that there was no unreasonable delay in carrying out Mr A's hip operation, as he needed treatment for other health issues to ensure he was fit for the operation. However, we considered that there was an unreasonable delay in transferring Mr A to the orthopaedic ward, which the board had accepted. Therefore, we upheld this aspect of Ms C's complaint.

In relation to the nursing care, we found that there was an unreasonable failure to communicate with Mr A's family about the risk of him developing delirium and that there was a delay in obtaining information about his likes/dislikes but we considered that reasonable steps were taken to minimise Mr A's risk of a fall. We also found that there was a failure to transfer all of his belongings with him when he moved to another ward but the board had subsequently found his belongings and returned them to Mr A's family. Finally, we noted that his bowel movements were not monitored and/or recorded appropriately. Therefore, we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to properly monitor and/or record Mr A's bowel movements. 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:

• Nursing staff should appropriately monitor and record patients' bowel movements, particularly after they have an operation.

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

Summary

Ms C complained that the board had refused her request for a genital cosmetic surgery procedure.

We took independent advice from a consultant gynaecologist (a specialist in the health of the female reproductive systems). We found that the board had appropriate guidelines in place for consideration of such requests and that Ms C did not meet the criteria for surgery. We did not uphold the complaint.

Summary

Mrs C complained about the care and treatment provided to her late husband (Mr A) at the Queen Elizabeth University Hospital. Mr A had liver cancer and was admitted to hospital to have a procedure to deliver chemotherapy directly into the tumour. This is known as transarterial chemoembolization (TACE). Mr A become unwell following the procedure and died. The cause of death was linked to some of the chemotherapy drug entering the pancreas and part of the bowel, causing them to become damaged. Mrs C complained about the care and treatment Mr A received in relation to this procedure.

We took independent advice from a consultant interventional radiologist (the type of clinician who carries out TACE procedures) and a consultant heptologist (a liver specialist). We found that the treatment Mr A received was reasonable, however, the adviser highlighted concerns that the consent process was inadequate. The complication that Mr A experienced is a rare but recognised risk of the TACE procedure. We found that there was no documentary evidence that the risks of the chemotherapy drug affecting another area of the body or death were appropriately covered during the consent process. Obtaining appropriate informed consent is an important part of a patient's care pathway. Therefore, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C that the consent process did not adequately document the risks of the procedure. 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 appropriately informed of the risks and benefits of transarterial chemoembolization procedures in line with national guidance on consent.

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