Health

Summary

Mrs C complained to us on behalf of her husband (Mr A) about dental treatment he had received from the practice. Mr A went to his dentist regarding a tooth that was causing him pain. The tooth was x-rayed and subsequently filled. Mr A experienced severe pain overnight after having the filling, and booked an emergency appointment for the following day. At the appointment, Mr A was seen by a different dentist. The dentist performed an extraction of the tooth. Mr A complained to the practice and said that he did not consent to having his tooth extracted. Mr A said he had discussed with his previous dentist that if the filling was not effective, then a root treatment would be the next course of action. Mr A said he would not have wanted his tooth extracted because there was already a missing tooth next to it. Mr A also complained that he had been told the level of bleeding he experienced was normal and he did not agree with this.

We took independent advice from a dentist and found that the dental records indicated that the dentist did consult with and obtain consent from Mr A. The adviser also confirmed that Mr A was correctly advised regarding bleeding. As a result of Mr A's complaint, the practice have included the extraction of wisdom teeth in the list of procedures that require written consent. Our investigation found that the practice did not fail to obtain consent to extract Mr A's tooth and that they correctly advised him regarding the level of bleeding following a tooth extraction. We therefore did not uphold the complaints.

Summary

Mr C complained about the care and treatment provided to him at the A&E department of Queen Elizabeth University Hospital. Mr C said that when he attended with chest and back pain and shortness of breath he was told he was suffering from muscular pain and given painkillers. Mr C attended again two months later and was diagnosed with pulmonary embolism (PE - a blockage of the artery that carries oxygen between the heart and lungs). Mr C complained that he had not been properly assessed on his first attendance and that the doctor had focused on the fact that he had been to the gym the night before. He said that he felt the diagnosis of PE was missed and that the delay may have led to permanent damage.

During our investigation, we took independent advice from an A&E consultant. We found that the diagnosis of muscular pain made when Mr C first attended A&E was consistent with his reported symptoms and the observations carried out. The adviser said that whilst there appeared to have been some small areas of moderate damage to Mr C's lungs, it was not possible to state that this was due to a failure to diagnose him with PE at an earlier point. We did not uphold Mr C's complaint.

Summary

Mr C complained about a delay in receiving a respiratory out-patient appointment. He waited 33 weeks in total for an appointment, when the board are targeted to provide first out-patient appointments for the majority of patients within 12 weeks of referral. The board confirmed that they were presently unable to see all patients in a timely manner, but said they were taking steps to try to reduce waiting times. They noted that the appointment Mr C eventually received was for an additional Sunday clinic that was set up to deal with long waits. We considered that Mr C's wait was excessive so we upheld his complaint. We noted that the board had apologised to him for his wait but that he subsequently waited a further two months for an appointment. We also considered that a further apology reflecting the full extent of his wait was appropriate. We also asked the board to provide us with further details of the steps they were taking to reduce waiting times and try to meet the 12-week target.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the length of time he had to wait. This apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• Take steps to reduce waiting times and work towards meeting the 12-week target for respiratory out-patient appointments.

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 care and treatment provided to her mother (Mrs A) at Queen Elizabeth University Hospital. Mrs A was admitted with back pain and faecal incontinence and was discharged after three days. Two days later, Mrs A was admitted to another hospital where she died three days after her admission. Miss C complained that her mother's discharge from Queen Elizabeth University Hospital had been inappropriate.

We took independent advice from a consultant orthopaedic surgeon, a consultant neurosurgeon, and a consultant gastroenterologist. The advice we received from the orthopaedic adviser was that the orthopaedic team caring for Mrs A had carried out all reasonable and appropriate tests and investigations during her admission, which included obtaining advice from the neurosurgery team. Mrs A had been assessed appropriately before discharge to ensure it was safe for her to go home.

The neurosurgery adviser did not identify any failings on the part of the neurosurgery team in the advice they gave to the orthopaedic team.

We also sought advice from a gastroenterology consultant, given that Mrs A's liver function test results were found to be abnormal. The advice we received was that the test results had been discussed appropriately with Mrs A's GP. It was established they had not worsened since previous tests and an out-patient referral had already been arranged. The decision to discharge Mrs A was reasonable.

Taking account of the evidence and the advice we received, we did not uphold Miss C's complaint.

Summary

Mrs C, who works for an advocacy and support agency, complained on behalf of her client (Mrs A). Mrs A fractured her ankle in a fall and was admitted to Victoria Hospital, where she had surgery to insert a plate and pins. Mrs A returned to hospital a few weeks later with signs of infection. Her wound was washed out, but staff decided not to remove the plate and pins at that time. Mrs A's health deteriorated and she spent some time in intensive care. Mrs A also suffered a heart attack while in hospital, and she remained in hospital for about six weeks. Following her discharge, Mrs A had a further fall and the fracture in her ankle was displaced again. Staff considered it was no longer possible to reconstruct the ankle, and Mrs A's leg was amputated.

Shortly after this, Mrs A returned to hospital feeling unwell, and with pain in her other foot. Surgery was planned to bypass an artery in her leg (to improve blood flow to her foot). This was not possible in view of Mrs A's underlying vascular disease, and her other leg was also amputated.

The board sent a written response to Mrs A's initial complaint, and also met with Mrs A and Mrs C. They considered the care and treatment were appropriate. At the meeting, Mrs A raised some additional concerns that were not in her original complaint and the board agreed to investigate these. Mrs C contacted the board numerous times to follow this up, and was told a response was being prepared. However, the investigation was not begun until four months after the meeting. By the time a response was prepared, managers decided not to send this, as so much time had elapsed and they did not realise that Mrs C had been following up a response.

After taking independent medical advice, we did not uphold Mrs C's complaints about care and treatment. We found the surgery and treatment for Mrs A's infection were reasonable, and the clinical records indicated the wound was healing well before Mrs A's second fall. We also found the problems with Mrs A's fractured leg did not contribute to the amputation of her second leg, which was due to her underlying vascular disease.

We upheld Mrs C's complaint about the board's complaint handling. We were critical of the significant delays and the failure to respond to the additional points, as well as the poor communication between staff and with Mrs C.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and Mrs A for their poor communication and failing to respond to the additional points of the complaint. This apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance
• Finalise and send the written response to the additional points of complaint.

In relation to complaints handling, we recommended:

• Where a complaint response takes more than 20 working days, the board should explain the reasons for the delay and agree a new timeframe.
• The board should meet any commitments they make about responding to complaints, unless otherwise agreed with the complainant.
• There should be effective communication between the staff handling a complaint and the managers making decisions about it.

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 (Mr A) about the care and treatment he had received before being diagnosed with colorectal cancer. Mr A had previously had a colonoscopy (an examination of the bowel with a camera on a flexible tube) and was diagnosed with diverticulosis (disease of the colon). He subsequently had a bowel screening test, which showed hidden blood in his bowel motion. He was initially told that a colonoscopy was the best way to look for the cause of bleeding, which in some but not all cases, may be due to bowel cancer. However, he was then told that a further colonoscopy would not be necessary.

Mr A subsequently attended his GP with abdominal pains and diarrhoea. He was referred to a general surgery clinic at Gartnavel General Hospital and an upper gastro-intestinal endoscopy (a medical procedure where a tube-like instrument is put into the body to look inside) and flexible sigmoidoscopy (a procedure that is used to look inside the back passage and lower part of the large bowel) were arranged. It was recorded that these showed mild gastritis (when the lining of the stomach becomes inflamed after it has been damaged) and that it was likely that diverticular disease (a group of conditions that affect the colon) had caused the positive bowel test.

Mr A continued to have abdominal pain and a scan of his abdomen and pelvis was arranged. This showed an area of thickening in a part of his colon, which either represented a tumour or diverticulitis. A further colonoscopy was then carried out and Mr A was subsequently diagnosed with cancer.

We took independent advice on the complaint from a consultant general and colorectal surgeon. We found that although it had taken some time to diagnose his cancer, there had not been any failings by the board and the timings in relation to each step of his care and treatment had been reasonable. The decision not to initially carry out a second colonoscopy had been in line with national guidance, which said that this should not be done where the patient has had a colonoscopy in the previous 12 months. We did not uphold this aspect of the complaint.

Ms C also complained that the board's response to her complaint incorrectly stated that a specialist nurse had told Mr A that he should see his GP for referral to his local colorectal service. Mr A disputed this and there was no record in his notes of what, if anything, the nurse told him. It was therefore difficult for us to comment further on what information the nurse gave Mr A. However, we found that the failure to record the advice given to Mr A was unreasonable and we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise that there are no contemporaneous notes in the records of what the nurse told Mr A. This apology should comply with SPSO guidelines 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 board should consider how they wish the clinical nurse specialists to communicate with primary care and with patients and how they will record this information, when decisions are made within the screening service not to proceed with investigation.

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 (Mr A) about the care and treatment provided by the practice to his late wife, (Mrs A). Ms C complained that the practice missed an opportunity to diagnose Mrs A with pancreatic cancer and that they failed to send her for a scan.

During our investigation, we took independent advice from a GP adviser. We found that the symptoms Mrs A had presented with were not consistent with pancreatic cancer and, therefore, there was nothing that would alert the practice to the need to arrange further investigations or scans. Therefore, we did not uphold Ms C's complaint.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mr A) about the care and treatment provided by the board to his late wife (Mrs A). Ms C complained that there was an avoidable delay in the board diagnosing Mrs A with pancreatic cancer and that there was a delay in carrying out a scan.

During our investigation we took independent advice from a medical adviser. We found that the actions of the board had been reasonable and that there was no delay in the diagnosis of pancreatic cancer as Mrs A had not been presenting with symptoms which would alert clinicians to a suspicion of this diagnosis. We also found that it was reasonable that a scan was arranged on an out-patient basis and there was no undue delay in carrying out the scan. Therefore, we did not uphold Ms C's complaint.

Summary

Mrs C complained about care and treatment she received during her pregnancy, delivery and postnatal period. Mrs C was unwell during her pregnancy and was latterly diagnosed with pre-eclampsia (a pregnancy-related condition involving a combination of raised blood pressure and protein in the urine) at the Southern General Hospital. She was transferred to the Royal Alexandra Hospital for a caesarean section as they had space available to care for her premature baby following delivery. Following the delivery, Mrs C was transferred to a maternity ward for around two days until her discharge home while her baby remained in the special care baby unit. Mrs C was seen by a community midwife at home and was subsequently readmitted to the Royal Alexandra Hospital where she was diagnosed with peripartum cardiomyopathy (a rare disease defined by heart failure towards the end of pregnancy or in the months following delivery). Mrs C was treated in the cardiology department before being transferred back to a maternity ward. While she remained in hospital, Mrs C experienced severe abdominal pain and a scan revealed that she was suffering from retained placental tissue (a condition where parts of the organ attached to the lining of the womb during pregnancy remain following birth). A procedure was carried out to remove these.

Mrs C had a number of concerns about her care and treatment and complained to the board. She complained that there had been unreasonable delays in diagnosing her with pre-eclampsia, peripartum cardiomyopathy and retained placenta. She further complained that she was discharged too early, that the placenta had not been removed during the caesarean section, that she was unreasonably encouraged to express breast milk, and that staff had not treated her compassionately. The board responded to Mrs C's concerns in writing and also arranged meetings with her to discuss her experience. Mrs C was unhappy with the board's handing of her complaints, and she brought her concerns to us for further investigation.

We took independent advice from a midwifery adviser and a consultant obstetrician during our investigation. We found that there had been no delay in diagnosing Mrs C's pre-eclampsia or peripartum cardiomyopathy, and that, taking her clinical records from that time into account, her discharge was reasonable. In relation to Mrs C being encouraged to express breast milk, our midwifery adviser highlighted no concerns. We did not uphold these complaints as a result.

We did, however, find that the placenta had not been fully removed during the caesarean section and that the risks of needing a further procedure (such that to remove retained placenta) had not been mentioned on the associated consent form. The obstetrics adviser highlighted concerns about the subsequent procedure to remove the retained placenta and pain that Mrs C suffered. We upheld Mrs C's complaints about the retained placenta and noted that the board had already offered apologies for the delay and pain she experienced. We made further recommendations in relation to these issues. We also upheld Mrs C's complaint about her treatment by staff. While the advice we received did not highlight any concerns about communication, we noted that, during their own investigation, the board apologised for poor attempts at humour on the part of a staff member and advised that Mrs C's experience would be used as a reflection and learning exercise. We made a recommendation about this.

Mrs C also complained about the way that the board had handled her complaint. We identified an issue in the way that the board determine the age of a complaint, however, this did not have a significant impact on their handling of Mrs C's case. We drew the board's attention to this but did not uphold this part of Mrs C's complaint.

Recommendations

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

• Staff should be familiar with the Royal College of Obstetricians and Gynaecologists (RCOG) guidance on the consent process for caesarean sections.
• Staff should provide patients with sufficient information to allow them to make informed choices about their treatment.

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 staff at the A&E department at Glasgow Royal Infirmary failed to provide him with appropriate treatment for his reported symptoms of acute eczema. The issues raised by Mr C included that his concerns about his condition were dismissed and that the registrar in emergency medicine who attended to him only glanced at his acute eczema when assessing him. Mr C said his eczema was infected and needed immediate proper treatment. Mr C also said the registrar failed to forward medical documentation about his eczema to his GP.

We obtained independent medical advice from a consultant emergency physician. The adviser explained that the registrar's visual inspection of Mr C's eczema was in accordance with relevant guidelines and was an assessment of the severity of his condition. The adviser said that Mr C's temperature, respiratory and heart rate were all normal and there was no clear indication from his medical records that he required immediate treatment for his eczema. It was noted that the registrar discussed Mr C's condition with him, gave him advice, prescribed medication to help ease the itching and advised him to see his GP for review and ongoing management. The adviser said there was no evidence that Mr C's treatment was inappropriate. The board acknowledged that a discharge summary did not appear to have been completed and sent to Mr C's GP, and the board apologised for this omission.

On balance, we considered that the board did not fail to provide Mr C with appropriate treatment and we did not uphold his complaint. However, we made a recommendation for action by the board regarding the forwarding of medical documentation about Mr C's eczema to his GP.

Recommendations

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

• A process for discharge summaries should be in place for when patients are discharged from A&E. This process should require staff to complete discharge summaries and send them to the patients' GPs.

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.