Health

Summary

Mr C complained that there was an unreasonable delay in the board providing him with treatment on his right eye. Mr C is diabetic and was referred to Gartnavel General Eye Hospital when he began having problems with the vision in his right eye. Mr C was seen by the vitreo-retinal (relating to the back of the eye) unit at the hospital eight weeks after the initial referral was made, and it was determined that he needed surgery on the eye. Surgery was carried out around three weeks later, and afterwards Mr C was told that he would not regain sight in the eye. Mr C complained that in the time he had to wait for an appointment at the hospital he went from being able to see to losing sight in his right eye.

In response to our enquiries, the board explained that when Mr C's referral to the hospital was made, it was not logged in the normal way on the electronic system and therefore was not given a clinical priority. The board apologised for this and said that they had taken measures to prevent the likelihood of this reccurring in the future.

During our investigation, we took independent advice from a medical professional who is an ophthalmologist. We found that, given the symptoms that were recorded in the referral, Mr C should have been given clinical priority and an urgent appointment. We found that the delay between Mr C being referred to the vitreo-retinal unit and being seen by them was unreasonable. We also found that had surgery been carried out at an earlier point, Mr C would have had more of a chance of maintaining a better level of vision. Therefore, we upheld his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delay in providing treatment for his right eye.

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

• Consultants should be aware that one of the biggest determinants of visual outcome following retinal surgery is the visual acuity when surgery is carried out.
• Referrals to the vitreo-retinal service should be appropriately logged.

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 to us about a sterilisation procedure she underwent and the events afterwards. Mrs C had chosen to have a procedure to make her sterile which involves putting devices (called Essure devices) in the fallopian tubes to block them. When Mrs C had the procedure, she became faint and therefore the procedure was stopped. Mrs C complained that she was told that one of the devices had not been placed and therefore she was not sterile. She said that due to how distressing she had found the procedure, she did not want to undergo it again to have the second device placed, and therefore she was told her only option was to have her fallopian tubes completely removed. Mrs C had this operation and afterwards was told that in fact both devices had been in place. Mrs C complained that the board did not investigate whether both devices had deployed, and that they did not reasonably communicate with her about the deployment of the devices.

During our investigation, we took independent gynaecological advice. We found that whilst the original mistake in thinking that one device had not deployed was not necessarily unreasonable, the consultants involved should have acknowledged that they could not be sure and should have offered Mrs C a scan before she underwent further treatment. We also found that whilst the records from the time of the original procedure were written as if the consultants were sure that one device had not deployed, the board's complaint response to Mrs C said that they had been unsure. We considered that due to the incorrect assumption at the time of the procedure that one device had not deployed, Mrs C underwent a potentially unnecessary operation to remove her fallopian tubes. We upheld this complaint.

Mrs C also complained that several months after she underwent the operation to remove her fallopian tubes, she developed a severe infection. She felt that this was due to poor post-operative care. However, we found that there was no evidence to suggest that the post-operative care she received was unreasonable or that the infection she developed was due to the operation. Therefore, we did not uphold this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to investigate whether both devices had deployed, and for failing to communicate with her reasonably regarding the deployment of the devices.

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

• Consultants should be aware of the possibility of being mistaken about non-deployment of Essure devices.
• Patients who have undergone Essure device placement should be offered a scan before deciding on further treatment, and this should be documented in the medical records.

In relation to complaints handling, we recommended:

• Complaint responses should be based on the contemporaneous records.

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 treatment provided to him during attendances at West Glasgow Minor Injuries Unit, Yorkhill and then at the emergency department of Queen Elizabeth University Hospital. Mr C had sustained an injury to his right calf muscle and he said that it was only following a subsequent admission to the Queen Elizabeth University Hospital, a day after his initial admission there, that he was diagnosed and treated for pulmonary embolism (a blockage in a blood vessel in the lungs) and deep vein thrombosis (DVT).

We obtained independent advice from a consultant in emergency medicine who said that the symptoms Mr C presented with at West Glasgow Minor Injuries Unit, Yorkhill were consistent with him having sustained a calf muscle tear and not a venous thrombosis. They found that the treatment provided to Mr C was appropriate.

With regards to Mr C's attendance at Queen Elizabeth University Hospital, the adviser said that medical staff had rightly suspected that Mr C may have had a pulmonary embolism and he was offered appropriate tests in order to diagnose this. However, it was recorded in the medical records that Mr C had declined these tests and opted to go home because the tests involved the use of needles to which Mr C had a severe phobia. It was further recorded that Mr C was judged as having capacity to make this decision. We received further advice that when Mr C was admitted to the Queen Elizabeth University Hospital the following day there had been changes in his clinical condition. The adviser found no failings in Mr C's treatment.

We were satisfied we had not seen evidence that there were any unreasonable failures to provide Mr C with appropriate clinical treatment for his reported symptoms of leg pain and we did not uphold his complaint.

Summary

Mr C complained about delays in being seen by the gastroenterology (medicine of the digestive system) department at the New Victoria Hospital. He considered that there was an unreasonable delay in contacting him after he was referred by his GP and that the board's communication in relation to appointments was insufficient. Mr C complained to the board but remained dissatisfied and brought his concerns to us for further investigation. Mr C considered that the board's handling of his complaints was unreasonable.

After taking independent advice from a consultant gastroenterologist, we upheld Mr C's complaints about delay and communication. We found that the 12 week waiting time target had been far exceeded and that communication about this was unreasonable. The board acknowledged these failings and apologised during their own consideration of the complaints.

We did not uphold Mr C's complaint that his concerns had been handled unreasonably by the board. We found the board had offered appropriate apologies and looked at ways to improve the service going forwards.

Recommendations

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

• Patients should be advised in a timely manner that they may not be seen within waiting time targets.

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 Mrs A about the care Mrs A received at the Queen Elizabeth University Hospital. Specifically, she complained about a delay in a scan being carried out, the temperature of the room Mrs A was in and that Mrs A's food and fluid intake were not adequately monitored.

We took independent advice from a consultant physician and a nursing adviser. We found no clear reason why Mrs A had been on bed rest which would have placed her at risk of loss of muscle tone. However, this did not appear to have had a significant impact on her, nor did we consider there was any undue delay in scanning her knee. We did not identify evidence related to the room temperature being unreasonably cold. We acknowledged the board had taken steps to address the provision of food and concluded that Mrs A's fluid and nutrition intake were reasonably assessed and monitored during her admission. We did not uphold Ms C's complaints.

Summary

Mrs C complained about the care and treatment she received at the Queen Elizabeth University Hospital. She had been admitted to the hospital for routine bladder surgery, but due to complications, she had to remain in hospital for four months. She complained that the board failed to ensure that her nutritional needs were appropriately met during her time in hospital. We took independent advice from a consultant urologist. Mrs C had been referred to a dietician after she had been in hospital for around a month and staff had then commenced feeding nutrition directly into her blood stream. However, we found that she should have been referred to a specialist dietician to address her nutritional needs earlier in her admission. We upheld this aspect of Mrs C's complaint.

Mrs C also complained about the catheter care management she received in hospital. Her catheter had fallen out and the procedure to put this back in was carried out by a junior doctor. However, the catheter went into her bowel. Mrs C said that, as a result of this, she had to have an ileostomy (where the small bowel is diverted through an opening in the stomach abdomen). We found that this problem could not have been foreseen and that it could not be concluded that this would not have happened if a more senior doctor had carried out the procedure. The follow-up care Mrs C subsequently received had also been appropriate. We found that the actions of staff in relation to this matter had been reasonable and we did not uphold this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise in writing to Mrs C for not referring her to a specialist dietician earlier. The apology should comply with SPSO guidelines on making an apology.

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

• Patients who will have a prolonged recovery time due to post-operative complications, particularly when it impacts their bowel and their nutritional requirements, should be assessed by a specialist dietician at the appropriate time.

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 on behalf of her late father (Mr A) about the failure to provide him with an appropriate scan following his presentation with significant weight loss over a short period of time. Ms C said Mr A had not been contacted about an appointment. Mr A was then phoned by a doctor who took the decision, without seeing Mr A, that a scan was unnecessary. Ms C said she believed that had Mr A been scanned, then the lung cancer he had would have been discovered and treated. Mr A had died suddenly of heart failure, and Ms C believed his heart had been under strain due to the untreated condition.

The board said that Mr A had been phoned on several occasions without success. He had then been written to, offering him an appointment. When the doctor had phoned Mr A it had been to ascertain if a scan was still necessary. The doctor's recollection was that Mr A had not wished to proceed with a scan and that he had stated that he had regained a small amount of weight. The board did not feel that Mr A's medical outcome was affected by the decision not to give him a scan.

We took independent medical advice and found that it would have been appropriate to review Mr A in clinic, given his symptoms. We noted that there was a significant gap between the phone conversation and the doctor writing to Mr A's GP, which meant that there were not appropriate records kept of the phone call. The advice we received was that this was in breach of General Medical Council guidelines on communication with patients. We found that there was evidence that the board made reasonable efforts to contact Mr A about his appointments, and so we did not uphold this aspect of Ms C's complaint. However, we considered it a failing that the doctor was unable to access Mr A's appointment schedule when he phoned him, and as such he could not advise him of the length of time Mr A would wait before his next appointment. We therefore upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to contact Mr A's GP in a reasonable amount of time and for failing to arrange a scan.

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

• The staff involved should reflect on the advice we received in relation to Mr A's need for an appointment for a scan.
• Staff should adhere to reasonable timescales when dictating clinical correspondence. At a minimum, these timescales should be in line with General Medical Council guidance.
• Clinical staff should be able to access the in-patient appointment viewing system to check 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

Mr C raised a number of concerns about the care provided to his mother (Mrs A) at Queen Elizabeth University Hospital. During Mrs A's admission, she was found to have fallen whilst in the bathroom. The nurse who found Mrs A did not identify any immediate signs of injury and noted that Mrs A had not reported loss of consciousness. Nursing staff subsequently carried out observations, and a doctor carried out an examination, noting no injuries. Following the examination, Mr C noticed that the bed sheets by Mrs A's elbow were spotted with blood and he reported this to nursing staff, who arranged for a small wound on Mrs A's arm to be dressed. The following day, Mr C noticed bruising around his mother's hairline and reported this to nursing staff, who had not previously noted this. A scan was then arranged, the results of which indicated that Mrs A had an acute subdural haematoma (bleeding in the space between the brain and the skull). Mrs A was subsequently transferred to a neurosurgical ward, and a procedure to evacuate the subdural haematoma was carried out.

A number of weeks following the fall, the board decided to undertake a significant clinical incident investigation. This took a number of months to be finalised, and it concluded that the assessment of Mrs A's risk of falling was not carried out appropriately and made a number of recommendations. To assess whether the board had taken appropriate steps in response to the failings identified, we took independent advice from a nursing adviser and a medical adviser.

Based on the nursing advice we received we could not conclude that Mrs A would not have fallen had the falls risk assessment been carried out appropriately, and had the appropriate interventions been in place. However, we considered that it was unreasonable that the board did not take the steps that they could reasonably have been expected to take to reduce the risk of Mrs A falling. We upheld this complaint, and we made a recommendation in relation to falls risk assessment.

Mr C was unhappy that nursing and medical staff failed to identify and treat his mother's injuries. In response to Mr C's complaint, the board acknowledged that nursing staff should have observed the bruising to Mrs A's head when delivering personal care and apologised that medical staff also missed this injury. The medical adviser was critical that a top-to-toe examination was not carried out by medical staff following the fall, and was also critical of how the medical examination was documented. We were satisfied that a dressing was appropriately applied to the cut to Mrs A's arm, and that a scan was arranged within a reasonable time after the bruising on her head was noticed. However, we found that the examination following the fall was not reasonable, and we upheld this aspect of the complaint. We made a number of recommendations for improvement.

We were also critical of the way the board handled Mr C's complaint. We found that staff had potentially missed an opportunity to recognise Mr C's complaint at an earlier stage, and we considered that this may have delayed the start of the complaint investigation. We noted a number of other shortcomings in the way the board handled and responded to Mr C's complaint. We upheld this aspect of the complaint and made a recommendation.

Recommendations

What we asked the organisation to do in this case:

• Send Mr C a written apology for failing to carry out a reasonable assessment of Mrs A following her fall.

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

• Junior medical staff should be trained on how to carry out appropriate assessments for patients who have fallen.
• The member of medical staff who assessed Mrs A should reflect and learn from the adviser's comments on record-keeping.

In relation to complaints handling, we recommended:

• Complaints should be handled in accordance with the proper procedure.

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 the board unreasonably failed to diagnose and treat the cause of her back pain. She had suffered chronic back pain since being involved in a motorbike accident a number of years previously. Ms C said that she had not been provided with a satisfactory resolution and explanation for her ongoing pain and she felt that the care and treatment she had received had been inadequate. Ms C said her mobility had been affected, and she continued to require to take strong pain medication.

We obtained independent medical advice from a trauma and orthopaedic consultant and a consultant neurologist. The advice we received was that both the orthopaedic and neurology care and treatment provided to Ms C was consistent and appropriate. The advisers did not identify failings in Ms C's care and treatment. We did not uphold Ms C's complaint.

Summary

Ms C complained on behalf of her late mother (Mrs A) about the care and treatment she received from the board. Specifically, Ms C complained about a consultant geriatrician's assessment of Mrs A's condition, as well as their communication with Mrs A and her family about her condition and treatment options. Ms C also complained that an out-of-hours doctor failed to communicate appropriately about Mrs A's condition and treatment options.

During our investigation we took independent medical advice from a consultant geriatrician and from a general practitioner. We found that the out-of-hours doctor's communication was reasonable. We also found that the consultant geriatrician's assessment of Mrs A's condition was reasonable. As a result, we did not uphold these aspects of Ms C's complaint. We did find that there were failings in how the consultant geriatrician communicated with Mrs A and her family. We, therefore, upheld this aspect of Ms C's complaint and made recommendations in light of our findings.

Recommendations

What we asked the organisation to do in this case:

• Apologise in writing to Ms C and Mrs A for failing to communicate appropriately about Mrs A's condition and treatment options. The apology should comply with the SPSO guidelines on making an apology.

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

• Consultants should attempt to communicate with patients during their assessments, in order to respect the patient's dignity.
• Patients or family members should be told of their right to a second opinion, or be given the opportunity for a further discussion with the clinician, if they feel dissatisfied with a clinician's assessment.

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.