Health

Summary

Mr C complained on behalf of his partner (Ms A) about the care and treatment Ms A received following an operation to her knee at Borders General Hospital. Ms A had been admitted for a planned day surgery but was kept in overnight for observation. In particular, Mr C complained that the board had failed to exercise proper care and attention to Ms A immediately after her operation, as no doctor or consultant saw her prior to discharge despite Ms A having been admitted overnight. He was also concerned that Ms A was advised to fully weight-bear following the operation.

We took independent advice from a consultant orthopaedic surgeon and a nursing adviser. The consultant orthopaedic surgeon indicated that, while there are a number of published protocols recommending non weight-bearing initially, the surgeon performing the operation was best placed to judge this, and that in this case the surgeon's recommendation to weight-bear was reasonable.

We were concerned about the lack of communication with Ms A during her overnight stay in the hospital, which the board had accepted and had apologised for. The advice we received from the consultant orthopaedic surgeon was that the delay in communicating Ms A's surgery details would not have an adverse impact of her prognosis. However, we considered that it would have been in line with established practice for Ms A to have been seen on a post-operative ward round during her hospital stay.

We also found that a hand-written operation note was inadequate in that it lacked detail, but we noted that Ms A had been managed in line with the post-operative instructions contained in the hand written note. Both the consultant orthopaedic surgeon and the nursing adviser were of the view that the overall the care and treatment Ms A had received had been reasonable. However, given our concerns about the lack of a post-operative ward round, the lack of detail in the hand written operation note and the lack of communication with Ms A, we upheld Mr C's complaint.

Recommendations

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

• A post-operative ward round should be part of routine surgical care.
• Post-operation instructions should contain adequate detail to allow the transfer of information.

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 to us that the practice had failed to provide appropriate care and treatment to her late mother (Mrs A). She said that her mother had attended the practice on a number of occasions and was given a diagnosis of a chest infection, whereas she was in the final stages of lung cancer. Ms C was concerned that the practice had concentrated on a chest infection being the cause of her mother's symptoms. In addition, a chest x-ray which was taken showed signs of a cavity in her lung which was not followed up or mentioned to Mrs A or her family.

We took independent advice from a GP adviser and concluded that there were some failings in the level of care provided. During the initial consultations it was appropriate for the GP to arrive at a potential diagnosis of a chest infection and we found that appropriate investigations including an x-ray and blood tests were performed. However, we considered that once the chest x-ray result had been received which showed a cavity on the lung, then further action should have been taken. This would either have been to repeat the chest x-ray within a defined time frame with a view to onward referral to a chest specialist, or to make a direct referral at that time to a chest specialist. Further action should also have been taken as Mrs A's blood results revealed that she was anaemic. We also concluded that, although the final outcome would not have altered, the diagnosis would have been reached sooner and this would have allowed Mrs A and her family to make decisions regarding future care and support which would be required. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to follow upon the blood results and x-ray result.

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 attended two consultations with the practice who had recently taken over from her previous practice. She had attended her previous practice five years earlier after she had experienced an increase in epileptic seizures.

Mrs C complained that, during these two consultations, the practice unreasonably focussed on the events of five years previously. She raised concerns that the practice placed undue focus on the reporting requirements of the Driver and Vehicle Licencing Agency (DVLA) and she found it difficult to get her health concerns across. Mrs C also complained that, during the first consultation, she was unreasonably prescribed the wrong dosage of epilepsy medication.

We found that the first of the two consultations was Mrs C's first with the practice altogether, following them taking over the running of her local practice. Her prior consultation with her previous practice noted concerns about the management of her epilepsy and an intention to notify the DVLA. We took independent medical advice from a GP, who confirmed that DVLA guidance requires patients with epilepsy to notify them. We considered that it was reasonable for the practice to discuss Mrs C's epilepsy and DVLA reporting requirements during her consultations. Therefore, we did not uphold this aspect of Mrs C's complaint.

Mrs C also complained that she was prescribed the wrong dosage of her epilepsy medication. We found that there had been a prescribing error and that the practice did not address this when responding to Mrs C's complaint. Therefore, we upheld this aspect of Mrs C's complaint. However, we noted that the practice acknowledged that the error was their fault and that this was fixed before any medication was actually issued.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the prescribing error and for failing to address her complaint about this.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

Mrs C complained about the care and treatment provided to her late husband (Mr A) at University Hospital Ayr. Mrs C felt that Mr A was kept in the emergency department for too long before being admitted to the hospital, and that he was not appropriately assessed during this time.

We took advice from a consultant in emergency medicine and a stroke consultant. We found that, overall, the care provided to Mr A by the emergency department staff was reasonable but that they failed to complete transfer observations and handover documentation. We found that the initial assessment of Mr A by the stroke team was poor. We acknowledged that the diagnosis of a stroke, such as the one Mr A suffered, can be difficult to diagnose, however, we found that there was a failure to scan Mr A in the appropriate manner and reasoning for decisions made were not documented clearly. Therefore, we upheld this aspect of Mrs C's complaint.

Mrs C also complained that there was a lack of communication to keep her advised of Mr A's diagnosis and treatment. We found that, overall, the medical records showed a reasonable level of communication with Mrs C and, therefore, we did not uphold this aspect of her complaint.

Finally, Mrs C complained that the board's handling of her complaint was unreasonable. We found that, throughout the complaints process, there had been a number of failings including delays and a lack of communication. Therefore, we upheld this aspect of Mrs C's complaint. However, since these events occurred, a new complaints handling policy had been implemented by the board and we therefore made no further recommendations on this point.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide Mr A with appropriate clinical treatment; and for failing to handle Mrs C's complaint in a reasonable manner. 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:

• Transfer observations and handover documentation should be completed appropriately by the emergency department to ensure patients are safe to be transferred and appropriate information is passed on to the receiving ward area.
• Assessments made by members of the stroke team, and reasoning for any decisions made, should be documented clearly.

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, who works for an advocacy and support agency, complained on behalf of her client (Mrs B). Ms C raised concerns that the board did not take appropriate action in relation to an ulcer on Mrs B's daughter (Ms A)'s heel. Ms A had a number of complex health conditions, including diabetes, and Ms C complained that neither the podiatrist that saw Ms A, nor the surgeon that saw her, raised any alarm about the fact the heel wound was getting worse.

We took independent advice from a podiatrist and from a surgeon. We found that Ms A should have been seen by the lead podiatrist at an earlier point and that this may have resulted in a swifter referral to a specialist team. We also found that the podiatry team failed to appropriately use diabetic foot screening tools. We further found that the surgeon that saw Ms A recommended a treatment that would not be normal practice and did not document any reason for this. We found that whilst they reasonably arranged a scan for Ms A's foot, this should have been done at an earlier point, and a management plan should have been made. We also found that the board's own complaints investigation did not identify or address the failings in the care provided to Ms A.

We upheld this complaint. However, since the events of this complaint, the board had implemented a detailed and comprehensive action plan to improve the care pathways for diabetic feet, which we found reasonable. We, therefore, limited our recommendations to areas which we felt had not been covered by the board's action plan.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B for failing to take appropriate action in relation to Ms A's heel wound and for failing to identify these issues in the complaint response. 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 with diabetic foot ulcers should be referred to the lead podiatrist or the vascular service as appropriate in a timely manner, and diabetic foot ulcers should be assessed in line with diabetic foot screening tools.
• In similar cases, surgeons should be aware of what action to take.

In relation to complaints handling, we recommended:

• The board's complaints handling procedure should ensure that failings (and good practice) are identified, and should enable learning from complaints to inform service development and improvement.

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, who works for an advocacy and support agency, complained on behalf of her client (Mrs B). Ms C raised concerns that Mrs B's daughter (Ms A) had not been provided appropriate care and treatment for an ulcer on her heel by practice nurses. Ms A had complex health conditions, including diabetes, and over several months practice nurses were dressing and monitoring the ulcer on her heel. The wound deteriorated and Ms A had to have an above the knee amputation as a result.

We took independent advice from a practice nurse. We found that the dressings and wound cleansing products used by the practice nurses were not in line with guidance, and that the ulcer was not assessed in line with Scottish Intercollegiate Guidelines Network guidelines. We also found that, given Ms A's other health conditions, the practice nurses should have taken steps to involve other specialisms at an earlier point. We found that it was not possible to say whether an earlier referral to a specialist would have prevented the deterioration in the wound, but we found that it would have resulted in a more controlled care experience. We also found that the practice's own complaints investigation did not identify or address the failings in the care provided to Ms A. We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B for failing to take appropriate action in relation to Ms A's heel wound and for failing to identify these issues in the complaint response. 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:

• Practice nurses and other clinical staff within the practice should be practising in accordance with the agreed wound formulary, unless there is a clear and robust clinical reason for opting for a non-formulary product, in which case, this should be clearly documented.
• Management of diabetic foot ulcers should be carried out in accordance with Scottish Intercollegiate Guidelines Network guidelines for the management of diabetic foot ulcers.
• Expert input should always be asked for if dealing with a difficult wound that is not healing.

In relation to complaints handling, we recommended:

• The practice's complaints handling procedure should ensure that failings (and good practice) are identified, and should enable learning from complaints to inform service development and improvement.

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 that he had been refused a patient escort to his hospital appointment. Mr C lives far away from the hospital and said that he could not travel on his own due to his health conditions. The board said that Mr C did not meet the criteria for a patient escort.

We took independent advice from a nurse. They said that there was insufficient evidence to demonstrate that the board had reasonably assessed Mr C's health conditions and their impact on his ability to travel. We considered that it was not clear why Mr C did not meet the criteria and what, potentially, would be sufficient to meet the criteria. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide Mr C with a full rationale for the decision not to allow him a patient escort.

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 attended the dentist to receive restoration treatment which included having a filling replaced, and previous fillings smoothed over as they still had overhangs of amalgam (mixture used to fill the teeth). The dentist who provided the treatment was undergoing vocational training, and was supervised by another dentist. Miss C complained that the treatment she received was below a reasonable standard.

We took independent advice from a dentist and found that overhangs of amalgam were still partially present, despite having been smoothed, and a significant gap was created between two teeth. Both the remnant amalgam and the gap were risks to Miss C's dental health, in particular as she had an underlying risk of tooth decay. We found that the treatment provided to Miss C was below a reasonable standard and, therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for providing treatment below a reasonable standard. 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:

• The dentist's supervisor should ensure that the dentist has a periodontal update, concentrating on the impact of poor restoration contouring.

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, an advocacy and support worker, complained on behalf of her client (Mr A) about the care and treatment he received at Ninewells Hospital. Mr A suffered an injury in which his fingertip was severed at the joint and he wanted to have surgery to have it reattached. However, he was referred for terminalisation surgery (where the finger is shortened and the remaining soft tissue is used to cover the amputated finger stump) instead. Following the surgery, Mr A experienced severe pain and his injury did not heal as quickly as he had hoped. Ms C complained that the board failed to provide Mr A with appropriate medical treatment and that nursing staff failed to appropriately assess and manage Mr A's pain before discharging him home.

We took independent medical advice from a plastic and hand surgeon, and from a nurse. The plastic and hand surgeon adviser considered that terminalisation surgery was the appropriate treatment for Mr A's injury. They explained that the outcome of reattachment surgery was likely to be poor and had higher risks than terminalisation surgery. Therefore, we did not uphold this aspect of Ms C's complaint.

The board accepted that Mr A's pain was not assessed and managed by nursing staff prior to his discharge and apologised for this. They explained that action had been taken to ensure learning from this case. The nursing adviser considered the nursing care was unreasonable so we upheld this aspect of Ms C's complaint. We asked the board to provide evidence of the action they have taken.

Summary

Ms C, who is an advocacy and support worker, complained on behalf of her client (Mr A). Mr A had an operation at Ninewells Hospital and continued to suffer pain for over a year after the operation. Ms C complained that:

Mr A suffered unreasonable pain after his operation;

Mr A had to wait an unreasonable amount of time to be assessed about his pain management;

the board took an unreasonable length of time to establish the source of Mr A's pain;

the board provided an unreasonable treatment pathway for Mr A's chronic pain; and

the board unreasonably failed to tell Mr A that he could have obtained alternative treatment outwith their area.

We took independent advice from consultants in surgery, anaesthetics and pain management. We found that Mr A did have to wait too long for a referral to the pain clinic, where there were further delays in him being seen. We upheld Ms C's complaint that Mr A had to wait an unreasonable amount of time to be assessed about his pain management.

We found that Mr A did suffer from pain after his operation, but that the care and treatment he had been given had been reasonable. We also found that the approach used to assess Mr A's pain was the correct approach, though it did take time. We found that Mr A's treatment options within the board had not been exhausted. We, therefore, did not uphold any of the other aspects of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the delays in him being seen by the pain clinic. 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:

• Action should be taken to ensure that patients are seen 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.