Health

Summary

Ms C complained about the care and treatment her father (Mr A) received at University Hospital Crosshouse. Mr A had cancer and was suffering from jaundice, requiring him to have bile drained from his body. Mr A had an Endoscopic Retrograde Cholangiopancreatography (ERCP) procedure (a procedure that examines the pancreatic and bile ducts) to try and drain the bile. After this he developed sepsis (a blood infection) and died in the hospital several days later.

We took independent medical advice from a consultant in gastroenterology and an intensive care consultant. We found that an ERCP procedure was the recommended and appropriate treatment to attempt to drain the bile and relieve Mr A's jaundice. Whilst we found that it was reasonable for staff to have carried out this treatment, we found that the procedure was unsuccessful as a result of the invasion of the cancer. The resulting undrained bile had led to Mr A developing sepsis, which is a recognised complication of this procedure. We also found that, although there were some delays in carrying out investigations, including the ERCP procedure, these delays were not unreasonable and did not affect Mr A's outcome. We noted that the surgical team could have recognised the deterioration in Mr A's condition more quickly, however, we found that this did not affect his outcome and found his overall medical management was acceptable. Taking account of the evidence and the independent advice we received from both advisers, we considered that, on the whole, the care and treatment Mr A received was reasonable and we did not uphold this complaint.

Ms C also complained that hospital staff had failed to communicate adequately with her and her family about the seriousness of Mr A's clinical condition and prognosis. We found that there should have been better communication with Mr A's family regarding the risks of an ERCP procedure and also regarding the severity of his illness and prognosis, in particular, when Mr A's condition deteriorated after the ERCP procedure. The board acknowledged that there were shortcomings in their communication with Mr A's family, for which they had apologised. They said that they had taken action to address these failings and we asked the board to provide us with evidence of this. We upheld this aspect of Ms C's complaint but, in light of the action the board had said they had taken, we did not make any further recommendations on this issue.

The gastroenterology consultant who we took advice from on this case commented that there were shortcomings in the level of detail and clarity of documented discussions with Mr A about his diagnosis and its management. We made a recommendation for action in relation to this.

Recommendations

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

• Discussions with a patient should be clearly documented with the relevant amount of clarity and detail.

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 support her child (child A) received from the Child and Adolescent Mental Health Service (CAMHS). During a period of absence of child A's regular therapist, child A was transferred to a new therapist who was not trained in the approach that the first therapist had used. The second therapist then left the service, and Ms C was told that, if child A wished to wait for the first therapist to return, they would need to be discharged in the meantime. Ms C also complained that CAMHS did not provide support to child A in response to a recent traumatic event, or in relation to a decision about child A's future schooling.

In response to Ms C's complaint, senior members of staff met with her, and it was agreed that child A would remain a patient with CAMHS, but that support would be provided by phone to Ms C until the first therapist returned. The board sent a written response to Ms C's complaint five months after this meeting, which confirmed these arrangements and apologised for the tone of a phone call with the CAMHS team leader. Ms C was not satisfied with the response, or the board's handling of her complaint, and she brought her complaint to us.

We took independent advice from a psychologist. In relation to the proposal to discharge child A while waiting for the first therapist to return, we found that staff acted reasonably, and so we did not uphold this complaint. However, we noted that it would have been helpful for them to have discussed Ms C's concerns and explored alternative options to discharge at an earlier stage, as we found that this was only done in response to her complaint.

We found that, whilst it was appropriate for the therapist not to raise the subject of a traumatic event with child A, they should have raised this with Ms C separately in order to explore the issues and offer indirect support. We also found that, although CAMHS was not responsible for the schooling decision, they had agreed to provide an assessment to support this decision and that there was an unreasonable delay in providing this. We upheld these aspects of Ms C's complaint.

Whilst the board had already apologised for the delayed complaint response, we were critical that Ms C was not kept updated during this delay, and that the board's response did not address key points of her complaint. We upheld this part of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for:
• not providing support in response to the recent traumatic event
• not completing the agreed assessment in time
• failing to update her regularly during their complaint investigation
• not responding to all of her points of 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 recent traumatic event is reported in relation to a child currently under the care of CAMHS, the therapist should seek to provide support, for example by raising the issue separately with the parent/carer.
• Agreed assessments should be carried out timeously.

In relation to complaints handling, we recommended:

• Where a complaint response takes longer than 20 days, the complainant should be kept updated on progress.
• Complaints should be responded to in full.

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 A). Mrs A was referred by her GP to hospital as she had an umbilical hernia. She had tests involving her chest, abdomen and pelvis which led to a suspicion of cancer, and a letter was sent to her GP advising that at the same time as her hernia was repaired, a biopsy would be taken. After these procedures, Mrs A was advised that it was likely that she had cancer. She was reviewed at a subsequent appointment where it was confirmed that she had advanced malignant disease.

Ms C complained about the way in which Mrs A had been told about her diagnosis and that she had not been given full information about the surgical procedures she was to undergo. She also said that the board had delayed in reaching a diagnosis and delayed in responding after Ms C made these complaints to them.

We found that Mrs A had been alone when her diagnosis was given to her and that no effort had been made to try to contact her husband before she was given bad news. We found little evidence that the procedures and the risks had been fully explained to Mrs A, despite the fact that she had signed the consent form as having understood. We upheld these aspects of the complaint. Although Mrs A felt that there had been a delay in diagnosing her, we found no evidence of this. She was seen within a month of referral, and tests were carried out in a timely way. We did not uphold this aspect of the complaint. However, we did find that when the board came to consider Ms C's complaints, they took too long, so we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should send Mrs A a formal letter apologising for failing to attempt to involve her husband or another supporter when she was given bad news.
• The board should send Mrs A a formal letter apologising for failing to discuss the risks of surgery with her.
• The board should send Mrs A a formal letter apologising for the delays in responding to her complaint.

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

• The board should ensure as far as possible that when patients are receiving bad news, they are personally supported by a friend or family member.
• The board should ensure that prior to elective surgery, a full explanation is given to the patient including information about the risks entailed. This conversation should be documented.

In relation to complaints handling, we recommended:

• The board should complaints should be responded to within the stated timeframes. Where this is not possible, the complainant should be updated.

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 by her medical practice for her back pain. She said that she was not appropriately investigated or diagnosed, and that there was a delay in her being referred for a scan.

We took independent advice from a GP. We found that when Mrs C presented with back pain, she was appropriately assessed and examined, and that appropriate action was taken as a result of these assessments. We also found that she was referred for a scan within two and a half weeks of presentation. We found that the care and treatment provided by the practice was reasonable and we did not uphold Mrs C's complaint.

Summary

Mrs C complained about her medical practice, specifically that they failed to recognise or suspect she had whooping cough given her symptoms until a blood test confirmed the condition. Mrs C told us that as a result of the failings, her health needs were not met and she posed an unnecessary risk to her family and other members of the public. Mrs C also raised concerns about the way the board handled her complaint in that a complaints manager had been involved in both supporting her and investigating her complaint.

We took independent advice from a medical adviser. We found that the standard of medical care and treatment provided was reasonable. We also found that, given the review of the investigation and report was undertaken by the head of services and not the complaints manager, the complaints handling was reasonable.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mrs A). She complained that it was unreasonable for Mrs A's GP practice to fail to diagnose her with whooping cough until a blood test confirmed this. She also complained about communication with the GPs and the impact this had on the diagnostic process.

We took independent advice from a medical adviser who specialises in general practice. We found that the standard of medical care and treatment provided to Mrs A was reasonable, and that there was no evidence of any failings. We did not uphold the complaint.

Summary

Mr C complained about the care and treatment his late wife (Mrs A) received from the Scottish Ambulance Service. Mrs A collapsed at home and Mr C phoned the ambulance service. Mrs A was taken to hospital and died shortly after arrival. Mr C said the ambulance service did not provide a reasonable standard of care and treatment for his wife and that there was an unreasonable delay in transferring his wife to hospital. He also said the ambulance service did not reasonably investigate and respond to his complaint.

We obtained independent medical advice on the case from a consultant in emergency medicine. The adviser said that after obtaining a first electrocardiogram (ECG) tracing (a test used to check heart rhythm and electrical activity), which was of adequate quality, the crew then spent 21 minutes obtaining a further five ECG tracings, the reason for which was unclear given that the first reading was adequate. The adviser also said the ambulance crew's clinical assessment of Mrs A was unreasonably minimal, especially with regards to regularly measuring her vital signs. For these reasons, we upheld this part of the complaint.

The adviser said that the time spent trying to obtain an ECG and communicate with the intended receiving hospital was unjustifiably prolonged. He said this was especially the case as Mrs A was only a ten minute drive from the hospital that she was eventually taken to, and because she was so critically unwell. The adviser said that when it became clear that obtaining the ECG and transmitting it to the first intended hospital was becoming problematic, the ambulance crew should have urgently taken Mrs A to the second hospital, which was the closer hospital, for medical assistance. From there a decision could have been made about Mrs A's onward transportation to the first intended hospital. We upheld this part of the complaint.

We also considered that the ambulance service did not reasonably investigate and respond to Mr C's complaint and we upheld this part of the complaint. We asked the ambulance service to provide documentary evidence of their remedial action they said that had taken regarding complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings identified in care, treatment and complaints handling. This apology should meet the standards set out in the SPSO guidance on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• The Scottish Ambulance Service should learn from this case. This learning should be across the organisation, and include governance and clinical staff (especially those involved in this case). Learning should be shared with appropriate support and training provided.
• Notes of patient encounters should be comprehensive, and completed timeously and accurately. The status of the patient, treatments administered and sequences of events should be clearly recorded. Clinical staff should be trained and competent to record such notes.
• Crews should understand when it is inappropriate to stay on scene with critically ill patients for prolonged periods, particularly when there are difficulties in obtaining ECGs and transmitting them to hospital.

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 A). Mrs A said that for a number of years she had been experiencing symptoms which had caused her concern. She attended her GP again because she had developed a rupture at her navel. Her GP made a referral for her to general surgery and she was given an appointment. However, before the appointment, Mrs A attended again at her GP and at the emergency department because of increasing abdominal pain. Her GP contacted the consultant surgeon asking if she could be seen sooner but she had already been given the first available appointment. At her hospital appointment, Mrs A was given a number of tests which showed likely peritoneal disease (disease of the lining of the stomach). After further tests, she was diagnosed with peritoneal mesothelioma (cancer that attacks the lining of the abdomen).

Ms C complained that Mrs A's GP had ignored the symptoms about which she had been complaining and that had she been referred to hospital sooner, she may have had an earlier diagnosis and her life expectancy may have improved. Mrs A complained to her medical practice, who said that she had not been a regular attendee at the practice and the majority of her symptoms had been respiratory for which she had received appropriate treatment. They added that when she presented with a hernia, she was immediately referred to hospital and that none of her symptoms had given any indication of her final diagnosis.

We took independent GP advice and found that all of Mrs A's symptoms had been investigated and treated appropriately. There had been no delay in referring her to hospital and there had been no suspicion of a cancer diagnosis to which a reasonable GP would have been alerted. We did not uphold the complaint.

Summary

Mrs C complained about her transvaginal tape (TVT) surgery not being performed appropriately at St John's Hospital, as she suffered heavy post-operative bleeding. Mrs C also complained that her post-operative bleeding was not treated appropriately at the Royal Infirmary of Edinburgh. In particular, Mrs C complained that she was given painful vaginal packing (an emergency treatment for excessive bleeding of the vagina) before she was referred for surgery to stop the bleeding.

During our investigation we took independent advice from a consultant gynaecologist. We found that Mrs C had suffered a rare but well-recognised complication of surgery, which did not evidence that the TVT surgery was carried out improperly. The adviser considered that Mrs C was given appropriate treatment for her post-operative bleeding as it was reasonable to try conservative management to try to stop the bleeding before referring Mrs C for surgery. We did not uphold the complaint. However, the adviser considered that the consent form should have documented the risks of TVT surgery so we made a recommendation in light of our findings.

Recommendations

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

• The risks of surgery discussed with a patient should be documented, in order to reduce the likelihood of a miscommunication or misunderstanding.

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 on behalf of her late husband (Mr A) who was being treated for a brain tumour at Dumfries and Galloway Royal Infirmary. Mrs C enquired with the board about the methylated status of Mr A's brain tumour as she had learned that it was useful to know this in deciding whether to accept chemotherapy. (Methylation is a chemical change which alters the MGMT gene, making treatment more effective.) The board told Mrs C that this information was not available at the time she enquired. Mrs C complained that the board failed to perform a test to confirm the methylated status of Mr A's brain tumour. She also complained that the board failed to respond to her queries within a reasonable timescale. The board responded and advised that the test was not available in the board area at the time.

In investigating Mrs C's complaint, the board carried out the test and it was found that the tumour was unmethylated. The board also confirmed that the methylation test is now carried out in all grade 3 and 4 gliomas (malignant tumours of the glial tissue of the nervous system) in the board area. We took independent advice from a consultant neurosurgeon. The adviser noted that knowing the methylation status of the tumour would have some bearing on the likelihood of the chemotherapy being effective. Our investigation found that even though the test was not routinely carried out by the board at the time Mr A was receiving treatment, the test could have been requested from another department. We also found the board failed to deal with Mrs C's complaints within the required timescale and they failed to advise her of their need to extend their response time. We upheld both of Mrs C's complaints and recommended that the board provide Mrs C with a written apology.

Recommendations

What we asked the organisation to do in this case:

• The board should provide Mrs C with a written apology, acknowledging that they failed to perform the test and failed to respond to her queries within a reasonable timescale.

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.