Health

Summary

Mrs C complained to us that that the board had delayed in diagnosing that she had Crohn's disease (a long-term condition that causes inflammation of the lining of the digestive system). Mrs C had significant symptoms of abdominal pain, diarrhoea and significant and progressive weight loss and had undergone a number of tests arranged by the board in relation to this. No diagnosis was made and Mrs C asked for a second opinion. She was referred to Wishaw General Hospital. Further tests were carried out, but it was not considered that there was evidence to support a diagnosis of Crohn's disease. Mrs C then attended a private hospital, where a diagnosis of Crohn's disease was made. Mrs C told us that a surgeon at the private hospital looked at a scan carried out at Wishaw General Hospital and found that it showed she had an abnormality in her bowel, which had not been identified by the board.

We took independent advice from a gastroenterology consultant and from a consultant radiologist. We found that the investigations carried out by the board in response to Mrs C's symptoms had been appropriate, thorough and timely. Although one of the tests had not been fully completed, it had been reasonable not to repeat the test, as other appropriate tests had been arranged. The scans carried out by the board did not show any significant abnormalities. We considered that the actions of the board had been reasonable and that there was no clear evidence of any failings or undue delays. We did not uphold Mrs C's complaint.

Summary

Ms C complained about the care and treatment provided to her brother (Mr A) for pain and other symptoms he reported in his legs. Mr A had been attending the practice about these issues. The practice referred him to a community clinic and deep vein thrombosis (DVT) service at the local NHS board during the period covered by this complaint. He was diagnosed with severe critical limb ischemia (obstruction of the arteries that reduces blood flow to the extremities) and later required amputation of his leg above the knee. Ms C was concerned that there was an opportunity to diagnose Mr A's condition earlier and that this could have resulted in a different outcome.

After taking independent medical advice from a general practitioner, we did not uphold Ms C's complaint. The advice we received was that appropriate timely referrals had been made for Mr A and that the practice had reasonably explored potential causes of his symptoms. We found that there could have been more information included in one of the referrals that had been made for Mr A, however, the advice we received was that this did not have any impact on Mr A's case. We made a recommendation in connection with this for learning purposes.

Recommendations

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

• Referral letters should include information in line with General Medical Council 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 raised a number of concerns about the care and treatment provided to his father (Mr A) whilst he was a patient at Hairmyres Hospital. Mr A had prostate cancer and was admitted to the hospital with symptoms of abdominal pain and diarrhoea. Mr A received treatment from the hospital's palliative care team and input from physiotherapy, occupational therapy and dietetics as staff sought to progress him towards discharge. Mr A's condition deteriorated throughout the admission and he died whilst an in-patient.

Mr C complained that staff did not provide Mr A with appropriate pain relief. We took independent advice from a nursing adviser and a medical adviser. The nursing adviser was satisfied that nursing staff monitored Mr A's pain in accordance with relevant guidance. However, they considered that the response to his pain, including prompting Mr A to use additional medications as required, was lacking on occasions. The medical adviser found that, for certain periods, medical staff had not achieved a good combination of painkillers for Mr A, and considered that there had been a delay in recognising that Mr A was reluctant to request additional medications when he felt he required them. We upheld this complaint and made a number of recommendations.

Mr C also raised concerns that staff inappropriately considered Mr A as being suitable for transfer to a care home. We found that the decision to transfer Mr A from hospital changed after his condition deteriorated. However, the medical adviser considered that it was appropriate for the board to have referred Mr A for transfer based on his condition at the time of the referral. We could not conclude that the board acted inappropriately in relation to plans to transfer Mr A to a care home and we did not uphold this complaint.

Mr C further complained that staff did not discuss the decision to give Mr A hormone therapy for his prostate cancer with Mr A's family. Having reviewed the records, the medical adviser considered that Mr A had the capacity to decide about further treatment for his cancer. The adviser explained that it was therefore reasonable for staff not to have discussed this decision with family members first. We did not uphold this complaint.

Finally, Mr C raised concerns that staff failed to communicate with Mr A's family about a DNACPR decision (do not attempt cardiopulmonary resuscitation – a decision taken that means a healthcare professional is not required to resuscitate the patient if their heart or breathing stops). We found evidence that a doctor discussed DNACPR with Mr C's wife, who is Mr A's daughter-in-law. The medical adviser said that the conversation about DNACPR should have been with Mr C or Mr A's wife, who were Mr A's next of kin. The adviser did consider that it was pragmatic to discuss goals of care and DNACPR with the most appropriate person available at the time, and noted that this was Mr C's wife. However, the adviser did not find evidence that doctors discussed DNACPR with Mr A and noted that there had been a delay in the senior clinician completing the DNACPR form. On balance, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to appropriately manage Mr A's pain.

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

• Nursing staff should be aware of the mental health changes associated with pain, as well as the observational changes with pain, so that patients are prompted to use pain relief when appropriate.
• Medical staff should recognise when a patient is reluctant to request pain relief and provide timely management to ensure that the patient receives appropriate pain relief for the recorded levels of pain.
• Communication and decision making surrounding DNACPR should be in accordance with the latest 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 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.