Health

Summary

Mr C complained about the care and treatment his late wife (Mrs A) received at Monklands Hospital. Mrs A attended the A&E department at the hospital and was diagnosed with a urinary tract infection. She was sent home with antibiotics and instructions to return if she still felt unwell. Mrs A returned the next day and was admitted for further investigations. Scans showed Mrs A had a large mass in her pelvis, hydronephrosis (an obstructed kidney) and pulmonary emboli (blood clots in her lungs). She was treated by urology doctors for the kidney problems, and then by gynaecologists for the mass in her pelvis, which was found to be cancerous. Mrs A was offered surgery roughly two weeks after her admission, but it was not possible to remove the cancer. Mrs A was given palliative care and died in hospital.

Mr C complained that Mrs A was not admitted when she first attended hospital, and that it took too long to diagnose Mrs A's cancer and offer her surgery. Mr C was concerned that gynaecologists did not review Mrs A until a week after her admission, and then waited for the multi-disciplinary team meeting around a week after that before making a decision about treatment.

The board responded to Mr C's complaint in writing and offered to meet with him if he wished. They explained that they considered the treatment provided was appropriate.

After taking independent emergency medicine and gynaecology advice, we did not uphold Mr C's complaints. We found that the treatment provided when Mrs A first attended hospital was appropriate, and that it was reasonable to offer antibiotics first with instructions to return if her symptoms continued. We also found the time-frame for diagnosing and treating her cancer was reasonable. While Mrs A was not reviewed by gynaecologists until a week after admission, gynaecologists discussed her condition with the doctors caring for her, and requested further tests to diagnose the mass, which were carried out before the gynaecology review. We also found that it was appropriate to wait for the multi-disciplinary team meeting before deciding on treatment, given the complexity of Mrs A's case.

Summary

Mr C raised concerns about the care and treatment the board provided to his late sister (Mrs A) at Wishaw General Hospital. These concerns extended to medical care, nursing care, and communication with Mrs A's family.

Mrs A had previously been involved in a road traffic accident, but had been discharged and was recovering. She attended Wishaw General Hospital after feeling unwell, and was admitted. She deteriorated the next day, but recovered. She experienced a further deterioration approximately ten days later. Her condition did not improve over the following days, and Mrs A died approximately four weeks later.

Mr C raised a number of specific concerns regarding the board's identification of sepsis (a blood infection), their actions regarding providing Mrs A with a cannula (a thin tube inserted into a vein or body cavity to administer medication or drain off fluid), and staff not transferring her to the intensive care unit when her condition deteriorated. He also raised concerns about nursing care, including management of Mrs A's wounds by nursing staff.

We took independent advice from a consultant in acute medicine and from a nursing adviser. Regarding medical care, we found that Mrs A should have been treated more aggressively for sepsis, and that there was some delay in relation to a cannula. We also found that Mrs A had been given a penicillin based antibiotic, though she was recorded as having an allergy. However, there was no evidence in the record that this impacted on her outcome. Regarding nursing care, we had concerns about wound care, and the general condition of the nursing records. Regarding communication with Mrs A's family, we found there was insufficient evidence of this in the records, given the seriousness of Mrs A's condition.

We upheld Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings in medical and nursing care provided to Mrs A, and for the poor level of communication with her family. 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:

• Staff should be aware of the recognition and management of sepsis.
• Staff should be confident in managing situations where vascular access becomes difficult.
• The microbiology or infection team could be involved in the management of complex cases.
• Staff should communicate adequately with a patient's family and should make sure that communication with the family is appropriately documented.

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 medical and nursing treatment she received over a series of hospital admissions to Wishaw General Hospital. Ms C suffered from problems with the discs in her spine and had required spinal surgery on more than one occasion. Ms C said that she had been subjected to lengthy delays during each admission and that there had been an absence of medical review. Ms C said her nursing care had been unprofessional and had resulted in some humiliating incidents. Ms C also complained that she had not been referred for physiotherapy. Ms C further complained that the board's communication with another health board regarding her care was unreasonable.

We took independent medical advice from a consultant neurosurgeon, a nursing adviser and a physiotherapist. We found that Ms C had received inadequate treatment and that there were delays in her receiving scans. This meant that the outcome of a surgery Ms C had to treat cauda equina (a disorder that affects the nerves) was not as good as it might have been. The board had accepted this and had taken appropriate action to improve the diagnosis of cauda equina. We found that, during the later admissions, Ms C had suffered from extended trolley waits in the A&E department before being reviewed by an appropriate specialist. We found it to be unreasonable that Ms C had been left for long periods of time without being seen by medical staff due to failures in communication between the on-call team and Ms C's original consultant. We recommended that the board implement a protocol to cover the re-admission of patients with recurrent problems, so that staff are aware of when they need to refer the patient to the original consultant who had been responsible for treating them. We found that Ms C was, on occasion, denied access to the radiography department due to capacity issues. We considered this inappropriate and said the board should alter their procedures to allow for urgent scanning in spinal cases.

We found that the board had correctly acknowledged the failures in Ms C's nursing care across all of her admissions. We found that, whilst some of the failings were significant, they were due to poor judgement by individual staff members rather than procedural failings. We noted that the board had made reasonable efforts since Ms C's experience to improve and monitor standards of nursing care.

We found that Ms C should have been referred for physiotherapy treatment. We did not agree with the board's view that treatment was not appropriate for Ms C and found that the failure to commence physiotherapy could have delayed her recovery.

We did not find that the communication between the board and another health board regarding Ms C's care was unreasonable and we did not identify any significant failings in this regard. We did not uphold Ms C's complaint about communication between health boards.

We found that Ms C had received an unreasonable standard of medical and nursing care during her admissions to hospital. The board had accepted this and made the appropriate changes to address the failings she experienced in most areas. We found, however, that on the basis of the advice we had received, there were still areas where the board needed to improve and we therefore upheld Ms C's complaints about her care and treatment.

Recommendations

What we asked the organisation to do in this case:

• Apologise in writing for failing to provide physiotherapy. 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:

• A protocol should be developed to ensure that scans for patients with suspected cauda equina are not delayed.
• A protocol should be developed so that when patients are re-admitted with a recurrent problem, staff are clear when care should be transferred to a patient's original consultant.
• The general assessment of when physiotherapy is justified should be reviewed.

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 that the board unreasonably failed to provide appropriate clinical treatment following her decision not to agree to a lumbar puncture procedure (a procedure where a needle is inserted into the lower part of the spine to test for conditions affecting the brain, spinal cord or other parts of the nervous system).

Mrs C was referred to a neurologist at Raigmore Hospital as she was experiencing a range of neurological symptoms. The neurologist conducted an examination, but made no definite findings. Mrs C advised that she did not wish to have a lumbar puncture. A range of scans were subsequently performed, but no definitive diagnosis was reached. Mrs C was subsequently seen by a second neurologist, who again raised the possibility of the lumbar puncture. Further scans were performed, however no definite diagnosis was reached over the course of approximately one year.

Mrs C raised a number of concerns, including that she was repeatedly pressured to have the lumbar puncture, that blood tests were not performed timeously, and that she had received inconsistent information from the two neurologists about her condition and the results of scans. The board considered that the care and treatment provided had been appropriate.

We took independent advice from a neurologist. We did not find evidence in the medical records to suggest that the neurologists acted inappropriately in offering the lumbar puncture. We found it would have been good practice for the blood tests to have been performed, but noted this was usually done before a patient would be seen by a neurologist. We found that the information provided to Mrs C about the scans and her condition was of a reasonable standard, given the complexity of her case, and that there were different views among the radiologists who reviewed the scans. On balance, we did not uphold Mrs C's complaint.

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.