Health

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.

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.