Health

Summary

Mrs C was diagnosed with jak2+VE primary polycythaemia (a cancer where the bone marrow makes an excess of red blood cells). Mrs C complained that staff at Beatson Cancer Centre failed to take appropriate action to establish the cause of abnormal blood tests, and that if they had taken action, a diagnosis could have been made earlier.

We obtained independent advice from a clinical adviser who noted that, in the year prior to Mrs C's diagnosis, a doctor at the oncology clinic at Beatson Cancer Centre had ordered a full blood count inadvertently, which was not part of the usual practice from an oncology perspective. The full blood result revealed a high haemoglobin level and, according to the relevant guidance, further action should have been considered to determine the cause of the high haemoglobin level. However, as the oncology doctor was unaware that a full blood count had been ordered, there was no reason for the doctor to establish the result of the full blood test. It was noted that Mrs C already had a long previous medical history of high haemoglobin levels, which the clinicians were aware of, and she was not displaying symptoms of polycythaemia when she attended for clinical review in the year prior to her diagnosis. We found that Mrs C's high haemoglobin level at that time was of minimal clinical significance and Mrs C did not appear to have suffered any complications as a result.

We also reviewed the process where, in addition to the electronic reporting of the abnormal result, the laboratory would phone the clinician to highlight the abnormal result. We found that the criteria was not met in Mrs C's case, and that, according to the standard operating procedure, a phone call to alert the clinician was not required in this case. As such, we found that there had not been a failure in the reporting process. We did not uphold the complaint.

Summary

Mr C complained that his GP practice failed to provide him with a GP appointment and a medical certificate for sickness absence. Mr C said he could not get a same day appointment when he phoned the practice in the mornings. We found there were other means of getting an appointment, such as booking online or booking an appointment for later in the same week. An audit of the practice’s appointment records showed there were appointments available in the week Mr C phoned the practice. We took independent advice from a GP adviser, and in their view the practice’s appointment system was reasonable.

Mr C said because he could not get an appointment he could not get a medical certificate and, when he spoke to a GP by phone, the GP refused to issue a certificate. We found that the GP asked Mr C to make an appointment for review, given that his circumstances had changed. In the adviser’s view, the GP acted in line with the General Medical Council's guidance, and the care provided to Mr C was of a reasonable standard. We did not uphold Mr C’s complaints.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mr A). Mr A had experienced symptoms of pain and numbness in his left foot. After he attended a number of consultations in the board's podiatry and orthopaedic services, he underwent surgery at Gartnavel General Hospital to fuse one of the joints in a toe. Following the operation, Mr A continued to experience pain and numbness and he attended a number of review appointments in the orthopaedic department before being discharged approximately a year after the procedure.

Ms C complained that the board did not perform appropriate orthopaedic surgery on Mr A, and said that Mr A was not informed of the possible side effects of surgery.

We took independent advice from an orthopaedic surgeon. The adviser was satisfied that Mr A was appropriately informed of the potential side effects of the procedure and that consent was obtained appropriately and in accordance with the board's consent policy. Furthermore, the adviser considered that the records indicated that the operation was carried out to a reasonable standard. In view of this advice, we did not uphold this aspect of Ms C's complaint.

Ms C also raised concern that Mr A did not receive appropriate treatment following surgery when he reported further concerns to the surgeon. We found that Mr A had attended three review appointments in the orthopaedic department following the surgery and that by the point of discharge the surgeon was satisfied that the toe joint had healed well. The adviser did not find evidence of failings in the aftercare provided to Mr A. We did not uphold this aspect of Ms C's complaint.

Summary

Mr C complained on behalf of his wife (Mrs A) that her medical practice failed to refer her to hospital for an audiology review as agreed during an earlier consultation. The practice apologised, but advised that the GP involved had no recollection of this agreement, nor was it recorded in Mrs A's medical notes. As we could find no additional evidence to allow us to conclude whether or not a referral was agreed, we did not uphold the complaint.

Summary

Ms C complained that her late father (Mr A) was wrongly diagnosed with metastatic cancer (a cancer which has spread from a primary site elsewhere in the body) , and then had to wait an unreasonable length of time to be informed of the mistake. Ms C said that Mr A’s mental and physical health suffered as a result.

Mr A was diagnosed with prostate cancer. As part of the diagnostic process he was given a bone scan. As the results were indeterminate, a repeat scan several months later was carried out which showed some changes and was reported by the radiologist as being suggestive of possible metastatic cancer. This was communicated to Mr A at a review appointment by his consultant oncologist. A scan subsequently carried out concluded that Mr A did not have metastatic cancer.

We took independent advice from a consultant oncologist and found that it was reasonable that Mr A was initially assessed as having metastatic cancer, and that it was appropriate based on the evidence available at the time that his oncologist had communicated this to him. We also found that after it was discovered that Mr A did not have metastatic cancer, this was communicated to him within a reasonable time-frame. We did not uphold this aspect of Ms C’s complaint.

Ms C also complained that Mr A was not referred to any specialist cancer support services and he was not offered additional support for pain management. Whilst we acknowledged that the board had accepted this and had apologised to Mr A’s family, we were critical of these failings. We upheld this aspect of Ms C’s complaint.

We also found that the board failed to respond to Ms C’s complaint within a reasonable period of time and we upheld this part of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and her mother for:
• failing to make Mr A aware of specialist cancer support services
• failing to offer Mr A additional support for pain management
• failing to provide an update on Ms C's complaint when it became clear that the 20 day timescale could not be met
• the unreasonable delay in arranging a meeting and providing Ms C with the minutes of this.
• These apologies 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:

• Patients should be informed of the specialist cancer support services that are available to them.
• Patients should be provided with additional support for pain management, where appropriate.

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 accuracy of a report which was written following a meeting attended by his ex-wife, a member of the child and adult mental health services, and staff from his son's school. Mr C felt that the report gave an inaccurate description of his behaviour and he was concerned that his ex-wife might produce the report in legal proceedings and that he would have to defend it.

We took independent advice from an adviser in mental health services and concluded that the report was factually accurate in that the information which was recorded had been discussed during the meeting. However, we could understand that the report could be interpreted differently by its readers as it was not entirely clear that the information discussed in the meeting was the opinions of those involved rather than actual facts. We noted that the board had clarified the issue in their response to Mr C's complaint. We did not uphold the complaint.

Summary

Miss C complained that the board unreasonably refused her breast reduction surgery. She maintained that this should have been done, not for reasons of appearance, but because of her extreme back and neck pain. The board did not agree and said that Miss C failed to meet the criteria necessary for the operation to be carried out.

We took independent advice from a consultant in plastic and reconstructive surgery. We found that in consideration of Miss C's case, the board had followed current Scottish Government advice. We did not uphold her complaint. However, we also found that the board had not told Miss C what to do should she continue to suffer severe back and neck pain, and so we made a recommendation about this.

Recommendations

What we asked the organisation to do in this case:

• Advise Miss C what to do in the event of non-surgical methods failing to improve her back and neck pain.

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 to us that he, his wife and daughter were removed from the practice's list. National Services Scotland (NSS) wrote to Mr C to say that his GP practice had asked NSS to remove him, his wife and their daughter from their patient list because of a breakdown in the doctor/patient relationship. Mr C said it was not clear why they had all been removed and that he had not been given a warning. Mr C believed it was because of a complaint he had made previously to us about the practice. As a result of the decision, Mr C and his family were distressed and left without the care of a GP practice while they found a new practice.

We took independent advice from a GP adviser. The advice we accepted was that there was no evidence that the practice had complied with their contractual regulations and General Medical Council guidance. We found that there had been an appointment between Mr C and practice nurses that was difficult for all concerned and that aspects of the appointment were challenging for staff. However, having reviewed in detail the witness statements and the entries in Mr C's medical records, we were not satisfied that it was reasonable for the practice to remove Mr C without first warning him that his behaviour was causing staff concern and giving him an opportunity to help restore the professional relationships.

We found that the practice had failed to give him an open and transparent response on their reasons for having him removed and that, as a result, he was concerned that he was removed because he had made a complaint. It is also of concern that the practice failed to take all reasonable steps to restore the professional relationship. We were not satisfied that the professional relationship with the practice had broken down to such an extent following the appointment with practice nurses that it affected the standard of clinical care provided, and so we found it to be unreasonable that Mr C was removed from the list. Similarly, there was no evidence that it was reasonable for the practice to remove his wife and child too. We upheld both complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for unreasonably removing him, his wife and his daughter from the practice list. The apology should comply with the 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 comply with the guidance and regulations on responding to staff concerns about patient behaviour.

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 his wife (Mrs A) received at Aberdeen Maternity Hospital after she became unwell following delivery of their child by caesarean section. Three days after the procedure, Mrs A required emergency surgery for a perforated bowel, resulting in a temporary ileostomy (where an opening is made in the abdomen to allow waste to pass out of the body) and further surgery to reverse this, which caused her a difficult and protracted recovery period. Mr C raised concern that they had been told by a doctor that the complications had arisen because the bowel had been accidently stitched to the caesarean section wound.

We took independent advice from a consultant obstetrician and a consultant general surgeon. We found that the consent form Mrs A signed, with the assistance of a doctor, agreeing to the caesarean section was not fully completed and did not warn her of the rare but recognised risk of bowel injury, which we were critical of. We also considered that it was likely that the bowel had been caught at the time of stitching, which meant that it was unlikely an adequate check of the wound was carried out by a second doctor at the time of the procedure. We upheld the complaint and made a number of recommendations to address these failings.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for the failings identified in relation to the consent process and her caesarean section. 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:

• Patients undergoing an elective caesarean section should be fully informed of the possible complication and risk of bowel injury and give clear, informed consent.
• All relevant sections on the consent form should be fully completed.
• The doctor who performed the surgery should reflect on the clinical incident at their appraisal to identify any training needs to ensure the matter does not recur.

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, who works for an advocacy and support agency, complained on behalf of her client Mr A. Mr A's late wife (Mrs A) had been diagnosed with lung cancer. Mrs A began to suffer severe neck pain which subsequently spread to her shoulder and arm. Mrs A was admitted to Dr Gray's Hospital at the request of her GP. Given that a recent scan of the shoulder had shown no problems, a further x-ray or scan was not requested by clinical staff at the acute medical assessment unit. Mrs A was discharged home the following day. Mrs A's pain continued and a few days later she was admitted to Aberdeen Royal Infirmary. X-rays and a scan were performed which showed that Mrs A's cancer had spread to two cervical vertebrae (neck bones) and to the brain. Mrs C complained that the board had failed to provide Mrs A with adequate care and treatment during her admission to Dr Gray's Hospital.

The board acknowledged that Mrs A should have been referred to the oncology team and that a neck x-ray should have been performed. They apologised for the delay in diagnosis and that they did not recognise or control the cause and nature of Mrs A's pain. The board explained that they have taken action following this complaint, including using the National Cancer Treatment Helpline, as well as considering direct referral to the oncology team. They explained that they are working to maintain the awareness of these mechanisms to prevent a recurrence through information on their intranet and documentation in induction packs. We have asked the board to provide evidence of these actions.

We took independent advice from a consultant in acute medicine. The adviser's view was that the possibility of the cancer spreading to the cervical vertebrae or the spinal cord should have been considered. The adviser said that Mrs A's pain should have been managed as a possible malignant spinal cord compression (an issue that develops when the spinal cord is compressed by bone fragments, a tumour, an abscess or other lesion. This is an issue that is usually treated as a medical emergency). The adviser's view was that there should have been a discussion with oncology and that the use of steroids and an MRI scan should have been considered. The adviser stated that they would expect doctors working in an acute medical assessment unit to recognise this and perform this role. In light of this, we upheld the complaint.

Recommendations

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

• The board should have a malignant spinal cord compression protocol.
• All clinical staff within the Acute Medical Assessment Unit should be made aware of the malignant spinal cord compression protocol.
• Clinical staff within the Acute Medical Assessment Unit should learn from this case.

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.