Health

Summary

Mrs C's husband (Mr A) underwent minor surgery at Victoria Hospital. He was discharged the same day, but died of a blood clot in the lungs two weeks after his surgery. Mrs C complained that the aftercare provided to Mr A was unreasonable. Specifically, she was concerned that Mr A should have been kept in overnight after the surgery, and she felt that when he came home from hospital he was not breathing properly.

We took independent advice from a surgeon. We found that a risk assessment tool had not been filled in. If it had been, it would have shown that Mr A had a number of risk factors for blood clots. This in turn should have led to the consideration of the use of a variety of preventative measures including Flowtron  boots (boots to prevent blod clotting), TED stockings (stockings used to try and prevent blood clots) and heparin (a medication which reduces the ability of the blood to clot), though we noted that these measures may not have changed the eventual outcome. Inconsistencies in the documentation meant that it was unclear if Flowtron boots or TED stockings had been used to prevent venous thrombo-embolism (VTE, or blood clots in the veins), however it was clear that heparin was not considered. We found that it was reasonable not to keep Mr A in hospital overnight, and did not consider that this would have changed the outcome. We found that there were likely to be other reasons for Mr A's breathlessness after the surgery, and did not consider that the blood clot would have been present so soon after surgery.

On balance, we considered that the aftercare provided to Mr A was unreasonable and we upheld Mrs C's complaint.

The board said that this complaint had alerted them to inconsistencies in practices, and confirmed that they were undertaking a review with a view to standardising and ensuring guidelines were followed. We asked for evidence of this and we also made some recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the poor record-keeping, and for failing to consider the use of heparin after Mr A's 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:

• Staff should ensure that patients' documentation is completed at every stage of their admission. The General Surgery VTE/Risk Assessment Tool should be completed for all patients.
• Staff in the day surgery unit should be clear about the board's policy for dealing with the presence of risk factors for VTE in day case surgery. (While  the board are reviewing this matter, interim measures should be in place to ensure that appropriate steps are being taken when risk factors are present).

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 time taken to refer her to a specialist in a different board area for her urology issues (urology is the area of medicine relating to the kidneys, bladder and urinary tract). She said she asked for this referral repeatedly, but that it took a number of months for the board to refer her. She also complained that the board did not send on some test results to her new consultant, so she was required to repeat these privately at her own cost.

In response to Miss C's complaint, the board said that referrals to another health board are not available on demand. They said that the consultant who reviewed Miss C's case and made the referral felt that it was appropriate to refer her on for more specialist advice at that time. The board acknowledged that they did not include a copy of the test results with the original referral, and they apologised for this. They said they had sent on the test results about two months later.

We took independent advice from a consultant urologist. We found that Miss C's condition was first investigated by gynaecology (the area of medicine that deals with the health of the female reproductive systems and the breasts) and, while Miss C did request a referral to the specialist during this time, she then agreed to continue with additional tests. Miss C then advised the gynaecology service that she was now seeing a private gynaecologist, and she was appropriately discharged from their care. About six months after this first urology appointment, Miss C was reviewed by urology, and there is no evidence in the medical records that she requested a referral to the specialist before this review. We considered that this time-frame was reasonable, and there was insufficient evidence to conclude that the board had failed to respond to her request for a referral. We did not uphold this aspect of Miss C's complaint.

In relation to the test results, we found there was evidence that the board did send these on two months after the referral (although it appeared they were never received by the specialist). We found the delay was unreasonable, but noted that the board had already apologised for this. We found that it was likely the specialist would have asked Miss C to repeat these tests in any case, so we did not recommend that the board refund this cost. We did not uphold this aspect of Miss C's complaint.

Summary

Mr C's late mother (Mrs A) was receiving palliative care (end of life care) for advanced pancreatic cancer at home in a sheltered housing complex. Mr C contacted the out-of-hours service a number of times over a weekend, as he was concerned about the amount of pain that Mrs A was in. On the Sunday evening, Mrs A was admitted to hospital and transferred to a hospice the following day, where she died several days after. Mr C complained that the board failed to provide a reasonable standard of medical care and treatment and that they failed to respond to his complaint in a reasonable way.

We took independent advice from a specialist in general practice medicine. We found that the medical care and treatment provided to Mrs A was of a reasonable standard and that she was admitted to hospital within a reasonable time. In relation to complaints handling, we found that the board had fully addressed the issues raised and took account of the evidence available at the time. We did not uphold Mr C's complaints.

Summary

Miss C had long standing problems with her ears and had a number of operations to deal with this. More recently she began to experience nocturnal seizures (seizures which occur during sleep) which she thought were related to the problems she already had. Miss C complained about the care and treatment she received and that it took too long to get a diagnosis for the seizures. She felt that she had not been listened to and had unreasonably been referred to the psychology service because of stress. The board, however, took the view that her symptoms were unrelated to her existing condition and that her care and treatment had been reasonable.

We took independent advice from consultants in neurology and ENT (ear, nose and throat). We found that the mix of the two conditions from which Miss C suffered required time and effort to investigate and to prove that they were unconnected. We found that the care she received from the ENT and neurology departments was thorough in order to exclude the possibility that Miss C's ear problems were the cause of possible brain disease. We were satisfied that she had been reasonably and appropriately treated. However, we also found that there was a delay of six months between the time her GP referred her and when she received her first out-patient appointment. Once her treatment started, we found that Miss C also had to wait too long for her scans. On balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the delay in receiving an out-patient appointment and the delay in scans being carried out. 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:

• Patients should receive clinical appointments and scans/tests in a timely manner.

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 complained about the treatment which his late brother (Mr A) received when he attended the accident and emergency department at Dumfries and Galloway Royal Infirmary. Mr C had received a phone call from Mr A early one morning saying that he had difficulty breathing. An ambulance was called and took Mr A to the hospital. Later that morning Mr C received a further call from Mr A saying that he was being discharged from the hospital and asking Mr C to pick him up. Mr C ensured that Mr A was settled in his house. However, Mr C later learned that Mr A had died. The cause of death was heart failure and Mr C felt that more care should have been taken at the hospital and that perhaps Mr A should have been admitted for further tests.

We took independent advice from a consultant in emergency medicine. We found that the staff at the accident and emergency department had carried out an appropriate examination of Mr A at the time, which included a history of heart problems. They had taken a chest x-ray, electrocardiogram (ECG - a test to check the heart's rhythm) and blood tests. Although there were subtle signs of heart failure from the results, we concluded that it was reasonable for the staff to diagnose that Mr A was suffering from a chest infection rather than heart failure. It was also reasonable that Mr A was prescribed antibiotics and discharged home. We did not uphold the complaint.

Summary

Mrs C complained about the management of her husband's (Mr A) insulin after he was admitted to Dumfries and Galloway Royal Infirmary for treatment of a stroke. Mr A has a history of diabetes mellitus (a condition that occurs when the body cannot produce sufficient insulin to absorb blood sugar) for which he administers insulin.

In responding to the complaint, the board acknowledged and apologised for a delay in Mr A receiving insulin one evening. The board considered that, during Mr A's admission, staff had followed the correct procedures but more checks of his blood sugar and ketone levels would have allowed staff to act earlier. The board set out a number of measures that they said they had taken regarding staff training and improvements as a result of Mr A's experience.

We took independent advice from a consultant physician specialised in diabetes mellitus. We found that management of the insulin was below the expected standard, given the possibility that diabetic ketoacidosis (DKA, a serious complication of diabetes that occurs when the body produces high levels of ketones) could have been prevented by earlier recognition, more frequent monitoring and more aggressive insulin administration. Therefore, we upheld this aspect of Mrs C's complaint.

Mrs C also complained that staff did not specifically inform her or Mr A that he had developed DKA and urosepsis (a secondary infection that develops in the urinary tract). Mrs C said they had only been aware that Mr A had low blood sugar levels. We found that when Mr A developed DKA and urosepsis, there was no record of this having been explained to either of them at the time. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A and Mrs C for the failings in communication. 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 that early recognition of the warning signs and prompt restorative action should prevent DKA from developing.

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 was due to have surgery on her leg at Dumfries and Galloway Royal Hospital but this was cancelled shortly before the scheduled time. Miss C complained that the board did not carry out her surgery and that the reasons for this were not properly explained to her. While the board apologised for the confusion surrounding the decision to cancel Miss C's surgery, they felt that the decision was appropriate as it was a major operation with significant risks and she had shown some recent improvement. Miss C was unhappy with this response and brought her complaint to us.

We took independent advice from a consultant vascular surgeon. We found that it was reasonable for the operation not to have been performed, but we considered that the decision-making process surrounding this could have been clearer. We found that the entries made at the time in Miss C's medical records indicated that the reasons for not going ahead with the surgery had been explained to her. We did not uphold Miss C's complaints but provided feedback to the board regarding their decision-making process for surgery in complex cases.

Summary

Mr C complained about the follow-up care and treament he received at Dumfries and Galloway Royal Infirmary. Mr C underwent surgery for prostate cancer in another NHS board area but follow-up care was to take place within his own area. Mr C complained to the board about the way they handled his follow-up care as there were a number of delays. The board decided to undertake a Significant Adverse Event Review (SAER) as a result. Mr C was provided with a draft copy of the SAER at a meeting, however, the response to his complaint was not supplied until a number of months later with a copy of the finalised SAER report. Mr C complained to us that the board had unreasonably failed to provide him with appropriate follow-up care and treatment. He was also concered that the board had not followed their SAER policy appropriately and that there had been unreasonable failings in the way they handled his complaint.

We took independent advice from a consultant urologist. We found that there was a lack of appropriate follow-up care for Mr C and that poor communication between staff caring for him in different board areas had contributed to the issues with his follow-up. We upheld this aspect of Mr C's complaint but noted that the board had acknowledged and apologised for this failing.

In relation to the SAER, we found that it was reasonable in its findings. However, it took far longer to complete than Mr C had been advised, and we found a lack of evidence that the board had kept him updated on their progress. We upheld this aspect of Mr C's complaint.

In relation to Mr C's complaints handling concerns, we found that there had been significant delays in the investigation process and that the board had acknowledged and apologised for this. We also noted that the SAER was a separate process from the investigation of Mr C's complaints and we considered that it would have been helpful had the board's complaint response more clearly addressed the specific concerns he had raised in his original letter of complaint.

Recommendations

What we asked the organisation to do in this case:

• Review Mr C's follow-up care plan to ensure that he receives the appropriate standard going forward.

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

• There should be systems in place to facilitate communication between staff where more than one NHS board is involved in caring for a patient.

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 treatment she received from her dentist, particularly in relation to the fitting of a crown which fractured multiple times and required repairs, and areas of untreated decay.

We took independent advice from a dental adviser. We found that the treatment Ms C received from the dentist was unreasonable and we therefore upheld the complaint. The repair carried out to the crown was unreasonable, as was the failure to investigate the cause of the fracture. There were failings in the dentist's record-keeping, and we found that Ms C was incorrectly charged for the repair. There were also failings around the untreated decay, though the dentist had already acknowledged and reflected on this.

We noted that the dentist had already apologised for some failings. They had also already taken steps to improve their practice and ensure these issues did not arise again, including carrying out an audit on clinical record-keeping, and undertaking some further training. We asked for evidence of these actions and we also made some further recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the shortcomings in treatment and record-keeping. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Refund Ms C the money charged for the crown repair.
• Consider reimbursing Ms C for the cost of the crown itself, since it broke twice soon after being fitted and had to be replaced.

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, who works for an independent advocacy service, complained that there was unreasonable delay in providing the required care and treatment to her client  (Miss A) when Miss A was admitted to Crosshouse Hospital after her Percutaneous Endoscopic Jejunostomy tube (PEJ tube - a feeding tube that is put inside an outer tube which goes into the stomach. The inside tube goes into the small intestine) became blocked. Mrs C also complained that the board's handling of her complaint was unreasonable.

We took independent advice from a gastroenterologist (a doctor who specialises in the digestive system). We found that the board's staff referred Miss A for an initial review, specialist review, arranged investigations and arranged for a replacement PEJ tube in a reasonable time. In view of this, we did not uphold Mrs C's complaint regarding the time taken to treat Miss A. However, we identified that there was no nutrition team involvement in Miss A's care, and that a nutrition assessment was not carried out. We were critical of this and made a recommendation to the board to address this matter.

Regarding complaints handling, we found that there was a lack of clarity as to how the board were investigating the issues raised by Mrs C. In addition, we found that the board did not adhere to the timescale required, nor did they appropriately update Mrs C on their progress. We, therefore, upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to clarify how the complaint would be handled and for not keeping her reasonably informed about the progress of the 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:

• The involvement of a nutrition team should be considered where stopping of nutrition due to a blocked feeding tube is the reason for admission, and the patient cannot be easily assessed with regards to nutrition status. Nutritional assessment of such patients should be documented.

In relation to complaints handling, we recommended:

• Complaints should be dealt with in accordance with the complaints procedure.

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.