Health

Summary

Mrs C complained to us that the medical practice had failed to provide appropriate care and treatment to her son (Mr A) who had attended an appointment with one of the GPs with symptoms of sore lungs and a cough. Ms C said that the GP had failed to listen to Mr A's lungs or chest and did not prescribe an antibiotic for him to take. Mr A was still unwell the following week and was taken to hospital, where he was diagnosed with pneumonia.

We took independent advice from an adviser in general practice medicine and concluded that the GP had provided a reasonable level of care. We found that the GP had examined Mr A's lungs and had found no signs of an infection. We also found that an adequate medical history was recorded and that it was not unreasonable for the GP to have diagnosed a viral infection. As such, it was not unreasonable that the GP did not prescribe antibiotics. We did not uphold the complaint.

Summary

Ms C complained on behalf of her late brother (Mr A) about the treatment he received from the practice in the four months prior to his diagnosis of lung cancer. She complained that the standard of care and treatment provided to her brother was unreasonable.

We took independent advice from a GP adviser who said that the initial symptoms Mr A presented with had led doctors to believe that he had a problem with his hormones, and that doctors had referred him appropriately at that time. When Mr A complained of different symptoms, which could have indicated cancer, his GP then asked him to complete a form to arrange an x-ray. The practice were unable to reach Mr A by phone and Mr A either did not receive the letter sent to him, or did not respond to it. When Mr A re-attended the practice it was noted that the x-ray request had not been returned and he was referred urgently to hospital that day. The adviser said that this was reasonable.

We accepted the advice we received and we did not uphold the complaint.

Summary

Mrs C, who has a background of lupus (an autoimmune condition that affects the body's defences against illnesses and infections) had a tumour detected during a scan. Her case was discussed by the multi-disciplinary team (MDT) and she was given an appointment with an oncologist to discuss chemotherapy (a treatment where medicine is used to kill cancerous cells) and radiotherapy (a treatment using high-energy radiation). The oncologist was concerned that, due to her background of lupus, Mrs C could suffer significant side effects from this treatment. The oncologist asked for further discussion of the case at a second MDT, where the possibility of surgery was also discussed.

Following this, the oncologist outlined the options of surgery or oncology treatment (chemotherapy and radiotherapy) to Mrs C and Mrs C agreed to have surgery. The surgery was carried out, but did not remove enough of the tumour to give a good chance of a cure. Mrs C was then offered oncology treatment as well.

Mrs C complained to the board that she was not told before the surgery that there was a high risk that she would also need oncology treatment. She said that she would not have chosen to have major surgery if she had known that she might still need the full oncology treatment. The board took several months to respond to Mrs C's complaints, because the surgeon and oncologist disagreed about some parts of the response. Eventually, the response was sent without the surgeon's agreement. Mrs C remained dissatisfied and brought her complaints to us.

Mrs C complained that the communication with her about her condition and treatment options was unreasonable. She also complained that the care and treatment provided was unreasonable. We took independent oncology and surgical advice. We found that, whilst the oncology treatment carried a high risk of significant side effects, the surgery also carried a high risk of being unsuccessful, and Mrs C would then need the oncology treatment as well. We found that there was insufficient evidence that these two options had been fully explained to Mrs C. We also found that consent for the surgery had only been sought on the day of the operation, and there was no evidence that the risks of the surgery had been discussed with Mrs C before this point. We also found that there was an occasion where Mrs C could have been given an update on her pathology results more quickly. We upheld these two aspects of Mrs C's complaint.

Mrs C also complained that there were unreasonable delays in her treatment. We found that the timeframes were reasonable and that quicker treatment would not neccesarily have impacted on Mrs C's outcome. We did not uphold this aspect of Mrs C's complaint.

Mrs C also raised concerns about the board's handling of her complaint, and particularly raised concern that she was unable to contact the complaints team by phone at certain points. We found that the board's complaint response was delayed for several months, that they had misunderstood part of her complaint and that Mrs C was not kept updated in this time. We upheld this part of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in communication, care and treatment and complaints handling. 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 be given full information about all their options before deciding on a treatment.
• Consent should not be sought on the day of surgery, unless there is an emergency situation.
• Consultants should be mindful of the need to communicate clearly and avoid misunderstandings.
• Patients should be fully informed and kept up to date on information relevant to their illness. Information should not be withheld unless they specifically request this, or if there is a potential risk of harm.
• In a similar situation, surgery should not be offered as a first line treatment without a full discussion of the multi-disciplinary team's views (both for and against) and options with the patient.

In relation to complaints handling, we recommended:

• The board should have a clear process for escalating disagreements about complaints responses, with senior management involvement, to ensure a whole-of-board response to the complaint.
• The board should contact the complainant to confirm the issues complained about as the first step in their investigation, in line with the Model Complaints Handling Procedure.
• The complaints team should be contactable by phone, with the facility to leave a message if there are no staff available.

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 mother (Mrs A) at Queen Elizabeth University Hospital. Mrs A was admitted to hospital with an infection in her knee. During the admission, Mrs A sustained an injury to her calf area whilst nursing staff were moving her to sit on the side of the bed. The day following the injury, a doctor inaccurately informed one of Mrs A's daughters that the injury was the result of a fall. Over the following days, Mrs A's condition deteriorated and she died.

Mrs C raised concern that nursing staff did not take appropriate steps to prevent her mother from sustaining an injury. We found that the board had completed an incident report for the injury which noted that Mrs A's skin was very fragile and concluded that nursing staff had provided appropriate care such that the injury was unavoidable. We took independent advice from a nursing adviser. We were satisfied that appropriate falls risk assessments had been carried out during the admission and we considered that the actions of nursing staff were reasonable and in keeping with the board's moving and handling policy. The nursing adviser agreed with the conclusion of the board's incident report, and we were unable to conclude that nursing staff failed to take appropriate steps to prevent the injury. We did not uphold this aspect of Mrs C's complaint.

Mrs C also raised concern about the way staff communicated with the family about the injury and the level of information provided about Mrs A's condition over the following days prior to her death. We took independent advice from the nursing adviser, as well as an adviser in general medicine. We found that the family were not told about the injury until the following day. The board said that this was because Mrs A wished to tell her family of the injury herself, yet we did not find evidence that Mrs A had stated this. When one of Mrs A's daughters was contacted, we found that a doctor provided inaccurate information about what had happened to Mrs A. We found that this should not have happened given that the injury was documented accurately in the nursing notes.

We also considered that there was evidence of a delay in recognising and responding to a deterioration in Mrs A's condition. The medical adviser was unable to conclude that Mrs A would have survived her illness if she received better care, however they did consider that the care was unreasonable. The medical adviser noted that the family did not seem prepared for Mrs A's death. The medical adviser was satisfied that the consultant did try to communicate that Mrs A might deteriorate further and that death was a possibility, but found that they may not have been quite explicit or clear enough when doing so. On balance, we upheld Mrs C's complaint about communication.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and her family for failing to immediately inform the family that Mrs A had sustained an injury and for the delay in recognising and responding to a deterioration in Mrs A's condition. 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:

• In a similar situation staff should promptly contact family members or significant others (as appropriate), in line with the protocol for informing next of kin when a serious incident occurs. If a patient states that they wish to inform their family of an incident themselves, this should be documented in the records.
• Medical staff should be aware of information documented in the nursing records when providing patients and their families with information about their condition.
• Staff should ensure that deteriorations are recognised promptly and should be aware of how to respond.

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 is an advocacy and support worker, complained on behalf of her client (Mr A) who underwent knee replacement surgery at Royal Alexandra Hospital. Following the operation, Mr A experienced a number of complications and continued to feel pain and discomfort.

Ms C complained that Mr A was not informed about the risks and complications of the procedure, including the possible outcomes. The board said that there were four interactions with Mr A prior to the surgery and that these interactions focussed on the need for, undertaking of and preparation for surgery. The board considered that this would have afforded the space and time to offer information and to answer any concerns that Mr A had. We took independent advice from a consultant orthopaedic surgeon. Whilst we noted that a consent form for surgery had been signed by Mr A, the adviser did not find evidence that the benefits and risks of surgery had been explained to Mr A. We were unable to conclude that Mr A was given the information he needed to understand the procedure and its risks in order to make an informed decision to consent to the treatment offered. We upheld this complaint and recommended that the board apologise for this failing. However, we noted that the board had since updated their consent form and consent procedure and we were satisfied that appropriate steps had been taken to try and prevent the same failing from happening again. Therefore, we did not make any further recommendations in connection to this.

Ms C also complained that the surgery provided to Mr A was not reasonable. The adviser explained that the complications Mr A experienced following the surgery were recognised complications of the procedure. The adviser did not find evidence of failings in the surgery performed on Mr A and we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for failing to obtain informed consent for 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.

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 was referred to the orthopaedic department at Glasgow Royal Infirmary after he suffered with osteoarthritis (chronic breakdown of cartilage in the joints leading to pain, stiffness and swelling) in the metatarsal phalangeal joint (the second joint from the end) in a toe on his right foot. Surgery was carried out to fuse the joint, but following this Mr C continued to experience pain in the toe. A further procedure was carried out to fuse the interphalangeal joint (the first joint from the end), however, this was not successful and the bones did not fuse together. Surgery was then carried out to remove a broken metal pin from the interphalangeal joint but Mr C continued to experience pain in the toe. After this the board considered that revision surgery was unlikely to be successful and Mr C agreed to the amputation of the toe.

Mr C complained that the first operation was not carried out appropriately. He also raised concern that the board did not provide him with appropriate treatment when he reported ongoing pain, as it had taken over two years following the first operation to resolve his pain. We took independent advice from a consultant orthopaedic surgeon. We found that the first procedure was carried out to a reasonable standard, and we did not find evidence that the first surgery had contributed to the issues Mr C subsequently experienced. We considered that the management of Mr C's treatment following the first operation was appropriate, and we did not consider that there was evidence of any unreasonable delays in Mr C's treatment. We did not uphold Mr C's complaints.

Summary

Mr and Ms C complained about the care and treatment that their daughter (Miss A) received from the board's Child and Adult Mental Health Services (CAMHS) and other agencies, which they believed to be inadequate and ineffective in terms of assisting her recovery from bipolar disorder. Specifically, the issues related to the provision of psychiatric treatment; the provision of adequate specialist services; a delay in a referral to another clinical specialist; delays in the board preparing a detailed care plan and delays in conducting a case review.

We took independent advice from a consultant psychiatrist and from a registered nurse. We considered that Miss A was provided with appropriate psychiatric care and had been offered therapies and interventions in line with national guidance. There was also evidence to show that efforts had been made to address difficulties that were the result of changes to staff and therapeutic approaches. We did not uphold the complaint about the provision of psychiatric treatment.

We noted that the board had accepted that the approach of outreach interventions in combination with clinic appointments had not resulted in a more consistent delivery of treatment options or an improved outcome. As a result of this, they had recommended a review of Miss A's care along with compiling a detailed written care plan. We found that there had been a lack of consistency, frequency and attendance at certain appointments. We upheld Mr and Ms C's complaint about the provision of specialist services.

In terms of the referral to another clinical specialist, we did not identify any unreasonable delay in this taking place because an appointment was offered within the national waiting time target. We did not uphold this aspect of the complaint.

Although the board had agreed to review Miss A's care and compile a written care plan, we upheld these aspects of the complaint and made further recommendations because we found that there had been an unreasonable delay in the board completing these to ensure the same issues do not happen again.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C and Miss A for the delay in compiling a written plan and conducting a formal review. The apology should meet the standards set out in the SPSO guidelines on apology available at https:www.spso.org.uk/leafletsand-guidance.

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

• In similar cases there should be a written care plan and agreed action, such as conducting a formal review, undertaken 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

Mrs C complained about the care and treatment provided to her late husband (Mr A) when he was admitted to the Queen Elizabeth Hospital for surgery to treat prostate cancer. In particular, she complained that the board unreasonably failed to identify possible complications of the surgery given Mr A's medical history. We took independent advice from a consultant urological surgeon. We found that the decision to offer the surgery to Mr A had been thought through in detail, and that every effort had been made to minimise the risk of bowel damage when carrying out the surgery. We also found that the consent form signed by Mr A referred to specific risks and complications associated with the surgery. Whilst we were concerned about aspects of record-keeping, the advice we received from the consultant urological surgeon was that, in recognising the possible complications of the surgery, the clinicians caring for Mr A had taken into account his medical history. We did not uphold this complaint.

Mrs C also complained about the nursing care and treatment Mr A received. We took independent nursing advice. We found that the nursing records were comprehensive and detailed and highlighted that the nursing care Mr A received was reasonable. As such, we did not uphold the complaint.

Mrs C also raised concern that the board had failed to identify the deterioration of Mr A's condition as early as they should have. We found that there was a delay in medical staff reviewing Mr A, and that consultant input should have been sought when Mr A's condition deteriorated. We also found that the level of communication with Mrs C was unreasonable when Mr A's condition deteriorated and there was a possibility of transfer to intensive care. In view of the failings identified we upheld this complaint.

Mrs C also complained that the board failed to provide a reasonable standard of treatment when complications were identified. We found that the clinicians caring for Mr A failed to acknowledge or act on a scan and x-ray finding in a timely manner, and as a result failed to recognise there was a possible bowel perforation. We upheld this part of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Make a formal apology to Mrs C for the shortcomings identified in relation to the care and treatment Mr A received.

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

• Relatives should be informed when a patient deteriorates.
• There should be appropriate escalation of deteriorating patients.
• There should be a system for communicating and acting on urgent results by clinicians in the relevant departments.

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 about the care and treatment her former partner (Mr A) had received at the Queen Elizabeth University Hospital and the Beatson West of Scotland Cancer Centre after he was diagnosed with cancer. Mr A had died within three months of being diagnosed. We took independent advice from a consultant clinical oncologist. We found that there were no failings in the diagnosis or management of Mr A's cancer and that the treatment provided to him was reasonable and appropriate. We did not uphold this aspect of Ms C's complaint.

Ms C also complained that the board had unreasonably failed to retain Mr A's personal possessions for collection by his next of kin after his death. We took independent nursing advice. We found that the actions of the board in relation to this matter had been reasonable and did not uphold this aspect of the complaint.

Ms C also raised concerns that the board had failed to assist her with investigating a link between Mr A's cancer and their son's health. Based on the evidence available, we considered that the board had reasonably tried to assist Ms C with this matter. We did not uphold this aspect of her complaint. However, we found that the board had not handled Ms C's complaint regarding this appropriately and we made a recommendation in relation to this.

Ms C also complained about the board's handling of her request for Mr A's medical records. She complained that the board had not given her the imaging and scans they held for Mr A. The board had told Ms C that they would not release some of the records because Mr A had told a consultant that he did not want them to be disclosed. We found that the consultant should have made a note of Mr A's request in his records. However, we did not identify any other failings and, on balance, we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for not handling her complaint appropriately. 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

Miss C complained that the dental care and treatment she received at Aberdeen Dental School and Hospital was unreasonable.

Miss C was seen by the board's dentists over a period of approximately a year. She said that there was a lack of care, unacceptable waiting times, unhelpful and unsupportive staff, and poor communication. She also raised a specific concern about an appointment where a crown was fitted.

We took independent advice from a dentist. While we found that the board provided reasonable treatment in a number of areas, we found that some aspects of the care and treatment were unreasonable. We found that there was no unreasonable delay, and there was no evidence that staff were unhelpful or unsupportive or failed to communicate with Miss C. However, we had concerns that there was no evidence that Miss C was shown the crown when it was placed. We also found that Miss C's latex allergy had not been highlighted in the clinical letters, meaning a treatment area was not prepared appropriately before a procedure, although we noted that this procedure did not ultimately take place. On balance, we upheld Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for failing to check the appearance of the crown with her before she was discharged. 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:

• Before patients leave hospital, staff should check that they are satisfied with their treatment and have no concerns.

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.