Health

Summary

Ms C complained that she had not received a reasonable standard of care at the Southern General Hospital. She was referred on two occasions with the same spinal symptoms but neither occasion had been treated as an emergency. Ms C said she had to wait an excessive length of time for an out-patient appointment, despite the severe pain she was suffering. Although she had phoned the hospital numerous times about her condition, she did not receive an appointment until she made a complaint. Ms C was offered an appointment a few days after she made this complaint and at the appointment she was told that she would be operated on a few days later. Ms C also complained that the board did not reply adequately to her complaints, and that they failed to communicate effectively with another health board about her condition and treatment.

We took independent advice from a consultant neurosurgeon. We found that it was not unreasonable for Ms C to be treated as an out-patient, given the information available to the board. The advice we received said that there was an unreasonable delay in providing an out-patient appointment for Ms C, which meant the nature of her pain was not considered fully. We therefore upheld the aspect of the complaint regarding Ms C's care and treatment.

We found that the board had expedited Ms C's appointment following her complaint. We considered this to be inappropriate given that Ms C had made contact through the appropriate channels in an effort to explain the pain she was suffering. We found the board had failed to respond adequately to Ms C's complaint and we upheld this aspect of the complaint.

We found that the board did not fully investigate a misunderstanding of communication between themselves and another health board, and so we also upheld this part of the complaint.

The advice we received was that, although the care and treatment Ms C had received had not been of a reasonable standard, there was no evidence that she had been deliberately misled by board staff, or that she had suffered permanent damage as a result of the delays to her treatment. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings identified in our investigation.

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

• Action should be taken to address extended delays in providing out-patient appointments, taking into account the learning from this case.

In relation to complaints handling, we recommended:

• The complaints handling in this case should be reviewed, and the reasons for the delays in providing a response should be identified.
• A reminder should be sent to all complaints handling staff about the need to inform complainants about the reasons for any delays in handling their complaints.

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 injured his shoulder at work and was seen by the orthopaedic team at the Royal Alexandra Hospital. It was decided that Mr C would have surgery on his shoulder and he was placed on the waiting list. A date was allocated for his operation and he attended a pre-operative assessment. However, due to an error, a second assessment appointment was also made for him. Mr C did not attend the second pre-operative assessment as he said he was not notified and as a result, his scheduled surgery was cancelled. He was allocated a new date for surgery but this was cancelled on the day due to an urgent trauma case. Mr C complained about these delays, and also about the standard of his surgery and follow-up care.

After taking independent advice from an orthopaedic surgeon, we upheld Mr C's complaint about delay. Although the cancellation of the second surgery was considered reasonable as urgent trauma cases would be prioritised, we found unreasonable failings around the cancellation of the original surgery date. We considered that had these not occurred, Mr C could potentially have had his surgery much earlier. The board acknowledged these errors during our investigation.

We also upheld Mr C's complaint about the standard of the surgery. The advice we received highlighted that while the operation itself had been carried out reasonably, Mr C had been given a steroid injection into his shoulder that was not appropriate.

In relation to Mr C's concerns about the follow-up care he received after his surgery, the advice we received was that this was reasonable and consequently, we did not uphold this part of his complaint.

Recommendations

We recommended that the board:

• apologise for the delay caused by the duplication of pre-operative assessment appointments;
• ensure that a robust system is now in place to prevent the repetition of this type of issue;
• apologise for the increased risk of infection caused by the use of a steroid injection at the time of surgery; and
• review the approach to steroid injections in joint surgery in light of the adviser's comments.

Summary

Mr C complained about the care and treatment provided to his late wife (Mrs A) by the board. Mr C complained that when Mrs A was diagnosed with throat cancer, she was prescribed radiotherapy treatment despite the fact that she had previously undergone radiotherapy some years prior. Mr C said that he had concerns that this contributed to Mrs A's later diagnosis of mouth cancer. Mr C also complained that the board unreasonably delayed in diagnosing Mrs A with mouth cancer.

During our investigation, we took independent advice from an oncologist and an ear, nose and throat surgeon. We found that it was reasonable for the board to prescribe radiotherapy for Mrs A's throat cancer, as the area did not overlap with the previously radiated area and therefore would not cause any harm. We did not uphold this aspect of Mr C's complaint. However, we found that prior to Mrs A's diagnosis of mouth cancer, there had been a failure to examine the inside of Mrs A's mouth despite her reporting symptoms and having previously had throat cancer. We found that this resulted in around a month's delay in diagnosing Mrs A with mouth cancer. Therefore, we upheld this aspect of Mr C's complaint.

Mr C also complained that the board had failed to deal with his complaint in a timely and reasonable manner. We found that the board had experienced difficulties in locating Mrs A's medical records, but that they had not explained this to Mr C until around two months after the response was due. We also found that the board had advised Mr C that the medical records were lost, when they were not. We found this, along with the lengthy delay Mr C had in waiting for a response to his complaint, to be unreasonable. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the unreasonable delay in diagnosing Mrs A's mouth cancer and for failing to deal with his complaint in a timely and reasonable manner. 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:

• Consideration should be given to establishing guidelines for a standard follow-up examination of patients who have been treated for head and neck cancer.
• Between the written notes and the clinic letter, it should be clear what has and has not taken place.

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 service, complained on behalf of her client (Ms A). She complained about the care and treatment Ms A received from Aberdeen Maternity Hospital following the birth of her child by caesarean section. Ms A had a protracted and difficult recovery period requiring further surgical intervention which she felt was due to a delay in diagnosing a hole in her bowel. Ms A was also unhappy that she was not given the opportunity to have Ms C present at a meeting which was arranged by the board's consultant obstetrician to discuss matters related to Ms A's obstetric care following the complaint being submitted.

We took independent advice from two advisers, one a consultant obstetrician and the other a consultant colorectal surgeon. We found that the care and treatment provided from the obstetricians and surgeons was of a reasonable and appropriate standard. There was evidence to show that Ms A's symptoms were appropriately monitored, investigated and regularly reviewed following the birth of her child. Given the findings of her assessments, we found that her initial care was reasonable, with no undue delay in surgical treatment going ahead. As such, we did not uphold this part of Ms A's complaint.

Whilst we considered that the board's consultant obstetrician acted appropriately in offering Ms A an appointment to review how she was getting on and to discuss her obstetric care, we considered that they should have informed Ms C of the date. It was clear that Ms A had been significantly affected by the events related to her care and required an advocate. We upheld this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide a written apology for failing to inform Ms A of the date of her appointment to discuss her obstetric care. This apology should comply with SPSO guidelines on making an 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

Mr C complained about the care and treatment provided by the practice to his late wife (Mrs A). Mr C complained that the practice had missed red flag symptoms prior to her diagnosis of carcinoma of the epiglottis (cancer in the tissue that covers the windpipe). He also complained that the next year, the practice missed red flag symptoms for cancer of the floor of the mouth.

We took independent advice from a GP. We found that Mrs A had suffered from throat discomfort for around three months before the practice referred her to a specialist. National guidelines state that persistent throat discomfort for three weeks should have led to an urgent referral, particularly as Mrs A was a smoker. We therefore upheld this aspect of Mr C's complaint, although we found that as the carcinoma of the epiglottis was cured, the delay in referral did not result in any significant injustice.

We further found that when Mrs A first presented with oral symptoms, the practice acted in an appropriate and timely manner, therefore, we did not uphold this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to provide appropriate treatment to Mrs 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:

• GPs at the practice should be familiar with the Scottish cancer referral guidelines.

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 has suffered from diabetes for some years. He recently changed GP practice and said his life and health had improved dramatically since moving to a new practice. He complained that his old practice failed to manage his diabetes care and treatment appropriately and that this may have contributed to him suffering liver damage.

We reviewed the care and treatment provided to Mr C for the management of both his diabetes and his liver. We considered the medical records and took independent advice from a GP and from a nursing adviser qualified in specialist diabetes care. Both advisers were satisfied that the practice had taken appropriate steps to monitor Mr C's condition and to attempt to manage his care. Therefore, we did not uphold the complaint.

Summary

Mrs C raised a number of concerns about the care that her mother (Mrs A) received from her medical practice. Mrs A had been diagnosed with terminal pancreatic cancer and was receiving care in her home from a multi-disciplinary team including her GP, district nurses and a Macmillan nurse. Once Mrs A's care needs increased, her GP referred her to a specialist palliative care facility, where she died.

We found that in response to Mrs C's complaint, the practice had reflected on the care they had provided to Mrs A and had identified a number of learning points to take forward and act on. We took independent advice on the case from a GP adviser who noted Mrs C's concerns about communication, but did not find evidence that the practice had communicated unreasonably with Mrs C or Mrs A. The adviser was satisfied that the practice had provided appropriate care and treatment for Mrs A's symptoms, and that the GP's role in an investigation into potential diabetes was reasonable. The adviser did not consider that the GP unreasonably delayed visiting Mrs A after she suffered a fall, and considered that the assessment performed at the subsequent home visit and referral to a specialist palliative care facility were reasonable. We did not uphold this complaint.

Mrs C also expressed concern about the level of support and information the practice provided to her in her role as a carer. We found that the practice did not send Mrs C the range of leaflets and resources that they usually send to individuals who have been identified as carers in terms of the practice's protocol. The adviser did not consider that this was unreasonable as it was the responsibility of Mrs C's GP, rather than Mrs A's GP, to provide this information. The adviser noted that the practice had provided some information at a late stage to Mrs C and considered the practice might want to consider taking steps to ensure that any information that is provided in these circumstances is provided at an earlier stage. We did not uphold this complaint, but made a recommendation.

Recommendations

We recommended that the practice:

• feed back the findings of this investigation to practice staff to ensure that information for carers is provided at an early stage.

Summary

Mrs C raised a number of concerns about the palliative care that her mother (Mrs A) received. Mrs A had been diagnosed with terminal pancreatic cancer and was receiving care in her home from a multi-disciplinary team including her GP, district nurses and a Macmillan nurse. Once Mrs A's care needs increased, she was referred to a specialist palliative care facility, where she died. Mrs C also complained about the way her complaint was handled by the board.

Mrs C complained about the nursing care her mother received. We took independent advice from a nursing adviser and a consultant geriatrician. Although we found that a number of aspects of the nursing care were reasonable, the nursing adviser was critical that nurses did not record the assessment of Mrs A's pressure areas for a number of months. We were also critical that although staff had ordered a pressure-relieving cushion for Mrs A, this was not delivered and the order was not followed up by nurses. We upheld this part of Mrs C's complaint.

Mrs C was also concerned about the level of input provided by a dietician. We found that the dietician had visited Mrs A on one occasion, and we were satisfied that the dietician had made a number of attempts to contact Mrs A following this. The geriatrician adviser also felt that Mrs A had received appropriate dietetic input whilst an in-patient at the palliative care facility, and both advisers felt that the board had responded reasonably to this aspect of Mrs C's complaint. We did not uphold this aspect of Mrs C's complaint.

Mrs C also complained about the communication with her about the reasons for her mother's admission, as well as the communication with her during her mother's admission. We noted that the Macmillan nurse specialist took a different view about the purpose of admission to that of Mrs A's GP, who had referred Mrs A. The nursing adviser said that staff were entitled to take different views, and did not consider that the Macmillan nurse took an unreasonable view. Regarding the communication during admission, we found that the documentation in relation to communication with Mrs C was not sufficiently detailed. Therefore it could not be determined whether staff had ensured that Mrs C had a full understanding of Mrs A's condition. We upheld this part of Mrs C's complaint.

Mrs C also expressed concern about the level of support and information she was provided with as a carer for Mrs A. We found that the Macmillan nursing records showed reasonable care and support. Mrs C was concerned that staff failed to explore whether she would have been able to care for her mother if her mother was discharged. We found that staff had discussed plans to discharge Mrs A and had referred her to social work, which the geriatrician adviser considered appropriate, as a carer assessment would have taken place. As Mrs A died before discharge was progressed, it was not possible to say what kind of carer assessment would have been undertaken. In response to Mrs C's complaint, the board undertook to explore carer support opportunities within palliative and frail elderly services. We did not uphold this complaint, but we considered that it would have been appropriate for the board to inform Mrs C about what steps it was taking in relation to carer support.

In relation to complaints handling, we noted that the board had not met the 20-working-day target for responding to complaints. However, Mrs C's complaint was detailed and involved multiple departments. We were therefore not critical that the board took longer than this and we found that Mrs C had been kept informed about the delay. We considered that the board's response was reasonable and we considered that the learning points that had been identified by the board were appropriate. We did not uphold this complaint.

Recommendations

We recommended that the board:

• feed back the findings of this investigation to the nursing staff involved in Mrs A's care to ensure that each request for equipment is followed up and to ensure that patients' pressure areas are monitored appropriately;
• take steps to ensure that conversations with patients and their families are recorded in detail in the clinical notes; and
• provide Mrs C with information about the steps taken to explore carer support opportunities within palliative and frail elderly services.

Summary

Mr C complained about various aspects of the treatment he received at the prison health centre. He complained that the board failed to carry out an appropriate assessment of him, and failed to adequately manage his pain. During the course of our investigation, Mr C was liberated from prison. He did not provide us with a forwarding address so we were unable to communicate with him. In the circumstances, we discontinued our investigation.

Summary

Ms C complained about a transvaginal ultrasound scan (an internal pelvic scan used for examination of a woman's reproductive organs) carried out at Dumfries and Galloway Royal Infirmary. Ms C complained that she was kept waiting unnecessarily, that inappropriate and unclean equipment was used and that the procedure was carried out in an overly rough manner which she felt led to vaginal and bladder infections. Ms C also complained about the way her complaint was handled.

During our investigation we took independent medical advice from a consultant obstetrician and gynaecologist with a special interest in ultrasound scanning.

We found that a member of staff should have checked on Ms C's wellbeing while she waited for her scan so we upheld that aspect of her complaint. We found that there was no evidence that the equipment was inappropriate or unclean so we did not uphold those aspects of the complaint. We found that while these types of scans can sometimes cause vaginal or bladder infections, this would not necessarily indicate that the scan was carried out improperly or in too rough a manner, so we did not uphold this aspect of the complaint.

In relation to complaints handling, we found that there was a delay in responding to Ms C's complaint which the board did not acknowledge, and we therefore upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for not updating her on the delay in her appointment and not checking on her wellbeing while she waited for her scan. Further apologise for the delay in acknowledging Ms C's complaint. These apologies 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:

• Patients should be kept updated if appointments for scans are delayed and it should be explained to them why they are waiting longer. Staff should check that patients are comfortable and should tell the sonographer is a patient is in discomfort or is highly anxious.
• The board should consider providing patients with an information leaflet in advance of their appointment. It should include information about what to expect on the day and warn about the possibility of delay. It should also detail the staff help and support available on the day, how patients can raise any concerns at the time, the clothes changing facilities available and the small risk of infection for all invasive procedures.
• Patients should be asked if they are feeling ok after the scan has started as some patients may not express concern unless prompted.

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.