Health

Summary

Miss C complained that the board unreasonably refused to perform liposuction (a  cosmetic procedure used to remove unwanted body fat) for her lipoedema (a  chronic fat tissue disorder in which fat cells build up, typically on the thighs, buttocks and lower legs, which causes tissue enlargement, swelling and pain. This tissue cannot be lost through weight loss). The board had criteria in place for providing this procedure and Miss C did not meet the criteria. Miss C complained that the criteria were unreasonable.

We took independent advice from a plastic surgeon. We found that it was reasonable for the board to have criteria in place for providing liposuction for lipoedema, and that the criteria was appropriate in order to balance the benefits and potential risks of the procedure. We did not uphold Miss C's complaint.

Summary

Ms C complained about the care and treatment provided to her by the board in relation to her hearing. Ms C had surgery to fit a hearing implant and after this she felt that her hearing deteriorated. Ms C also developed tinnitus (a ringing or buzzing in the ears). Ms C further complained that the communication with her from clinicians with regards to her hearing was not reasonable.

We took advice from an ear, nose, and throat consultant and an audiologist (a healthcare professional who specialises in hearing, balance and related disorders). We found that there was no suggestion that the reduction in Ms C's hearing was due to the surgery, and that clinicians involved in her care had provided a reasonable standard of care. We also found that the records showed a reasonable level of communication with Ms C. We did not uphold Ms C's complaints.

Summary

Mr C complained on behalf of his late wife (Mrs A) about the care and treatment she received from her GP practice. Mrs A attended the practice with stomach pains but it was not until two years after her pain began that she was diagnosed with cholangiocarcinoma (CCA, a very rare cancer of the bileduct). Mr C complained that the practice had delayed in carrying out appropriate tests and investigations. The practice said that Mrs A had been treated and cared for reasonably. They explained the rarity of her illness and said that that her symptoms had not been specific for a diagnosis of CCA. Mr C was unhappy with this response and brought his complaint to us.

We took independent advice from a GP. We found that, as well as Mrs A's illness being extremely rare, it was also very difficult to diagnose at an early stage and was often found incidentally. Mrs A initially attended the practice with abdominal pain for which she was appropriately treated. There was no indication at that time for further investigations and Mrs A noted an improvement. She did not return to the practice with abdominal pain until two years later. At this time, all her liver tests were normal; and showed no cause for concern. However, as her symptoms worsened, she was admitted to hospital and was diagnosed with CCA. We found that the care and treatment Mrs A received from the practice was reasonable and, therefore, we did not uphold this complaint.

Summary

Mr C complained on behalf of his late wife (Mrs A) who was diagnosed with cholangiocarcinoma (CCA, a very rare cancer of the bile duct) at Ninewells Hospital. Mr C was concerned that there had been a delay in providing the diagnosis and that, had appropriate tests and investigations been carried out sooner, Mrs A's death may have been avoided. Mr C was also concerned that after diagnosis, the board failed to make further more timely investigations about the spread of the disease (particularly to her bones) for which treatment may have been available. Mr C complained to the board who told him that Mrs A's illness had been life limiting but that throughout her illness, her treatment had been reasonable and appropriate. Mr C was unhappy with this response and brought his complaint to us.

We took independent advice from a consultant oncologist (a doctor who specialises in cancer treatment). We found that Mrs A's illness was very rare and diagnosis was not obvious; it was often an unexpected finding on a scan. Mrs A had stomach problems a few years before her cancer diagnosis, for which she received appropriate tests and at that time there was no evidence that she had cancer. Mrs A had no further stomach problems for two years until she was sent to hospital for a scan and it was at this time that she was diagnosed with CCA. We found that there had been no delay in diagnosis. After her diagnosis, Mrs A was given palliative chemotherapy (cancer treatment that is not designed to cure the disease, but rather prolong life and minimise symptoms) and responded well. Her symptoms were managed as it was not possible to operate, however, Mrs A was later admitted to hospital as she had become jaundiced (where the skin and/or eyes become yellow in colour). Her disease had progressed and was later found in her bones but we did not find that there had been any missed opportunities for treatment that would have changed Mrs A's outcome. We found that her care and treatment had been reasonable. Therefore, we did not uphold Mr C's complaint.

Summary

Mrs C complained that the board unreasonably discharged her from a community mental health team. She believed that she was discharged due to the absence of her usual community psychiatric nurse (CPN), who had been off work for a number of months at the time of discharge. Mrs C said that she had not been regularly seen or supported during this absence, only receiving two appointments, the focus of which were her discharge from services. While complaining to the board, she also became aware that her previous diagnosis of bipolar disorder (a mental health condition marked by alternating periods of elation and depression) had been changed to a possible diagnosis of borderline personality disorder (BPD, a disorder of mood and how a person interacts with others). Mrs C complained that she had never been informed of this change and that the board failed to communicate with her appropriately.

We took independent advice from a CPN. We found no evidence to suggest that Mrs C's discharge was related to staffing issues. Prior to the CPN's absence, she had a clear care plan in place and was being seen around every two weeks. One of the aims of the plan was to explore a possible alternative diagnosis of BPD. There was also recorded agreement that any future discharge would be clearly planned in advance and communicated, to ensure that this happened in a supportive manner. We considered that the overall decison to discharge Mrs C was reasonable. However, the adviser explained that, under Scottish Government guidance, the board should have implemented an Integrated Care Pathway (ICP) which would define the care and support offered to people with personality disorders. We noted that it did not appear that the board had an ICP in place for BPD.

We also found that there was a lack of continuity in the support provided to Mrs  C once her CPN was absent. Prior to discharge, Mrs C had been without support for around four months, despite her care plan stipulating that she would be seen every two weeks. The adviser noted that the care plan should have been updated to reflect the CPN's absence but this did not happen. They also confirmed that, while Mrs C was aware that a diagnosis of BPD was being considered, no formal diagnosis had been given. However, they noted that Mrs C had now been referred back to the board for the specific purpose of reaching a clear diagnosis.

Overall we found that the decision to discharge Mrs C was reasonable. However, the manner that this was handled and communicated to Mrs C was not in line with the agreed care plan or relevant guidance. Therefore, we upheld both of Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to appropriately handle her discharge and failing to clearly communicate her change of diagnosis. 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:

• The board should have an ICP to guide care provision for patients with BPD.
• Care plans should be reviewed and appropriately amended when a member of staff is absent from work long-term to ensure consistency of care.

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 provided to her late husband (Mr  A) at Ninewells Hospital. Mr A was resident in a care home and had Alzheimer's disease. He was referred to the emergency department by his GP as he was suffering from hip pain and could not bear weight. The GP asked that staff at the hospital rule out bony injury as a cause of Mr A's symptoms. X-rays were carried out and Mr A was discharged back to the care home after staff found no significant changes from previous x-rays. Four days later, an emergency referral was made for Mr A and he was admitted to hospital. Subsequent tests showed that Mr A had an abscess (a painful swelling caused by a build-up of pus) in his hip. It was determined that he was not suitable for surgery and Mr A was referred to the palliative (end of life) care team. Mr A died in hospital a few days later. Mrs C complained that Mr A's care in the emergency department was unreasonable and that there had been confusion over his palliative care referral. She also complained about how the board handled her complaint.

We took independent advice from an acute care consultant and from an emergency medicine consultant. The advice highlighted that Mr A's pain and inability to straighten his leg should have prompted further action by the staff who saw him in the emergency department. However, there was no indication that earlier treatment would have changed the outcome for Mr A. We also found that national guidance from the Scottish Intercollegiate Guidelines Network (SIGN) in SIGN 111 recommended tests that could have identified Mr A's infection earlier and that the care he received fell short of what he required as a patient with dementia. Therefore, we found that the care and treatment Mr A received was unreasonable and upheld this aspect of Mrs C's complaint.

In relation to communication around palliative care arrangements, we found that the board had identified failings and had apologised to Mrs C. Therefore, we upheld this aspect of Mrs C's complaint but made no recommendations as we considered that this had been adequately dealt with by the board.

Finally, we found that Mrs C had not been kept properly updated during the complaints process, which exceeded the 20 working day timescale set out in the board's complaints handling procedure. 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 the decision to discharge Mr A without further investigation of the cause of his hip pain and for the failings in the handling of her complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at:https://www.spso.org.uk/leaflets-and-guidance.

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

• Emergency department staff should take appropriate account of patients' cognitive impairments given that these make them more vulnerable to healthcare associated harm.
• SIGN 111 should be followed for patients with suspected hip fracture.

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

Miss C complained about the medical treatment her late mother (Ms A) received at Ninewells Hospital before her death. Ms A had been admitted to hospital on three occasions with exacerbation of chronic obstructive pulmonary disease (COPD, a disease of the lungs in which the airways become narrowed). It was then diagnosed that she had heart failure and Ms A died a week after her final admission. Miss C considered that there had been a delay in making a diagnosis of heart failure, as staff wrongly assumed that Ms A had COPD and delayed in carrying out the tests that showed she had heart failure.

We took independent advice from a consultant in acute medicine and from a consultant radiologist. We found that the investigations carried out in the hospital had been reasonable and appropriate and that it was reasonable that staff initially considered Ms A had COPD. We noted that it can be difficult to distinguish between heart and lung disease, especially when both are present together, and that there had not been an unreasonable delay in making a diagnosis. We did not uphold this aspect of Miss C's complaint.

Miss C also complained that staff had failed to adequately communicate with her and Ms A. The board had accepted that there were failings in relation to communication and we upheld this aspect of Miss C's complaint. We found that the main impact of this was that Miss C was not prepared for Ms A's sudden death. However, we were satisfied that the board had apologised for and addressed these failings whilst they were dealing with Miss C's complaint and we did not make any recommendations in relation to this matter.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mrs A) that the consent process followed for an above knee amputation of Mrs A's leg was unreasonable. Mrs A had been admitted to Balfour Hospital for treatment of severe chronic leg ulcers and amputation was planned when other options were exhausted.

We took independent advice from a consultant physician. Although we found that Mrs A had been fully aware of the plan for surgery and had discussed this with staff on the ward, we found that the consent form had not been signed until the day of the procedure. We also found that there was a lack of evidence in both the medical records and the consent form to confirm that the risks and benefits of the surgery were appropriately discussed with Mrs A. The advice we received highlighted that this did not follow national guidance on consent and that, while Mrs A's post-operative care was appropriate, her delirium had not been monitored using the appropriate test. We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A that the consent process for her above the knee amputation was unreasonable. 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:

• The consent process should follow national guidelines. Consent should be taken, where possible, prior to the day of surgery and what is discussed as part of the consent taking process, including risks and benefits, should be documented.
• Where appropriate, patients should be tested for post-operative delirium.

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 arranged an emergency appointment at the out-of-hours dental service as she was suffering from toothache. The dentist performed the first stage of a root canal treatment, however they experienced difficulty in accessing all the root canals. Ms C's tooth pain worsened and she had to return to the out-of-hours dental service the following day and she opted to have the tooth extracted. Ms  C complained that the dentist failed to properly explain the treatment options to enable her to give informed consent. She also complained the dentist failed to provide the appropriate treatment and that, had the dentist informed her of the difficulty they would have performing the treatment, she would have opted to have the tooth extracted.

The board explained that the dentist had difficulty accessing all the root canals and this would explain why Ms C had significant post-operative pain, however, they did not consider that the dentist failed to provide the appropriate treatment or that they failed to appropriately explain the treatment options.

We took independent advice from a dentist. We found that it was not possible to identify from scans taken of Ms C's mouth that the root canal treatment would be so difficult to perform, therefore the appropriate treatment was provided. We also found that the information provided to Ms C in terms of treatment options was reasonable in the context of an emergency service setting. We did not uphold Ms C's complaints.

Summary

Mrs C complained about the respiratory care (care of the lungs and other organs) and treatment provided to her by the board. She said that she did not feel she was given appropriate follow-up care and that this resulted in her respiratory problems becoming worse.

We took independent advice from a consultant in respiratory medicine. We found that Mrs C was appropriately investigated and that no follow-up was necessary. We also found that there was no evidence that her respiratory problems had been caused by, or became worse as a result of, lack of follow-up. We did not uphold Mrs C's complaint.