Health

Summary

Mr C was referred to a urologist at Raigmore Hospital to have his history of erectile dysfunction and low testosterone investigated. Mr C raised a complaint nine months later as he had not received an appointment and was distressed by his ongoing symptoms.

The board informed Mr C that there was a long waiting list. Mr C raised further concerns that he had not received an appointment, 13 months after his original referral. It took until 19 months after his referral for Mr C to be seen by a urologist.

We took independent medical advice. We found that Mr C's wait to see a urologist was entirely unreasonable and significantly exceeded the Scottish Government's waiting time of 12 weeks for a new out-patient appointment. We were also concerned that the board had not provided evidence to show whether steps had been taken to reduce the waiting time of the urology clinic.

Recommendations

We recommended that the board:

• apologise to Mr C for the unreasonable delay in his receiving a urology appointment; and
• provide clear evidence showing the steps they are taking to meet the 12-week waiting time target for appointments in the urology department at Raigmore Hospital and what they will do in cases where they are unable to meet the target.

Summary

Mrs C complained that an orthopaedic consultant at Raigmore Hospital did not examine her, and instead transferred her care to a different orthopaedic doctor. Mrs C acknowledged that there had been electrical power loss at the hospital affecting the ability to carry out an x-ray of her painful foot. However, she felt that the doctor could have assessed her, given her medical records were available.

We took independent medical advice from an orthopaedic consultant. We were unable to clearly determine whether the doctor had access to all of the relevant electronic medical records and previous x-rays taken, given the power loss. We considered that it was reasonable for the doctor to rearrange the appointment and transfer Mrs C's care to the orthopaedic consultant who had previously treated her. However, we were critical that Mrs C had to wait a further three months to be reviewed. We considered this wait to be unreasonable. The board have since taken steps to address the delays by employing more staff.

Mrs C also complained that the board's response to her complaint was delayed and contained inaccurate information. We did not identify evidence to support her concern that the board's response was inaccurate. In addition, we found that although there was a delay in the board replying to the complaint, this was not unreasonable given that Mrs C was kept informed about the progress of the board's investigation in accordance with national complaints handling guidance.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for the additional delay in being reviewed.

Summary

Mr C was receiving care and treatment from one of the board's community mental health services. He complained that he was unhappy with aspects of his care and services provided by the board.

We took independent advice from a psychiatric adviser and a mental health nursing adviser. The psychiatric adviser found that Mr C's initial referral to the consultant psychiatrist had been lost, and we were critical of this. However, they were satisfied that Mr C received reasonable treatment from the psychiatrists he saw and considered that it was evident from the records that this treatment had resulted in an improvement in his condition. The mental health nursing adviser was satisfied that, for the period the community psychiatric nurse (CPN) was engaging with Mr C, the CPN's input was reasonable and of an appropriate standard. However, the mental health nursing adviser was critical that, following a referral to a practitioner of CBT (cognitive behavioural therapy), the CPN discharged Mr C from their caseload without waiting to see whether the CBT service would take on Mr C. The mental health nursing adviser considered that this had denied Mr C the opportunity to explore other support, and considered that Mr C's continuity of care had been interrupted and that this was unreasonable. We found that the CPN's clinical correspondence could have been better worded, and although the adviser did not consider that the CPN's actions could be considered to be a breach of professional conduct, they felt that this was a learning point. We therefore upheld this aspect of Mr C's complaint.

Mr C also complained that when the CPN was absent, the board did not provide him with a replacement CPN. We noted that the board had written to Mr C to ask him to call the service if he wanted a different counsellor in the absence of his CPN. The board said that if there was no response to this letter within two weeks, no follow-up letter would have been sent. The mental health nursing adviser considered that asking Mr C to maintain continuity of care was unreasonable, especially at a point when Mr C had not yet been seen by a psychiatrist. They noted that Mr C therefore had no CPN input for four months, which was unacceptable. We upheld this aspect of Mr C's complaint.

Mr C also complained about a weight-loss programme provided by the board. In particular, Mr C complained that he was not provided with recipes as part of the programme, and that the programme was not sufficiently holistic. We took independent advice on this aspect from a nursing adviser. They noted that recipes were not a specific aspect of the programme and considered that it was reasonable for the practitioner to recommend that Mr C use the library to find recipes. They also found that it would not have been appropriate for the practitioner to have supported Mr C with his other issues, including his mental health. We therefore did not uphold this complaint.

Mr C said that whilst the doctors and psychiatrists he saw considered that CBT would be useful for him, when he saw the CBT practitioner, they did not think that it would be suitable. Both the psychiatric and mental health nursing advisers agreed that the CBT practitioner had provided reasonable reasons for their decision that Mr C was not a suitable candidate for CBT. We did not uphold this complaint.

Mr C also complained that the board did not respond reasonably to his complaint. Although we considered that many aspects of the board's complaints handling had been reasonable, we found that it had taken the board a disproportionate length of time to respond to Mr C's complaint. We therefore upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• feed back the adviser's comments to the CPN involved so that the CPN reflects upon their style of report and letter writing;
• take steps to ensure that referrals within the community mental health team are received and appropriately processed;
• review the discharge procedures of the community mental health team, taking into account the adviser's comments;
• review the community mental health team's practice of writing to patients (in similar cases) and giving them two weeks to respond if they wish to have continued community mental health team input; and
• apologise to Mr C for the failings identified in this investigation.

Summary

Mr C, who received treatment for high blood pressure and kidney disease, complained that GPs at his medical practice had not monitored his blood pressure reasonably, and that this had caused damage to his kidneys. In response to Mr C's complaint, the practice said that his blood pressure had been monitored in accordance with the relevant guidelines.

We took independent medical advice. The adviser was satisfied that it was appropriate for the practice to measure Mr C's blood pressure at whatever time he attended for an appointment and noted that there was no requirement in the guidelines stating that blood pressure cannot be taken in the morning, or after a patient's medication has been taken. The adviser considered that both Mr C's blood pressure and kidney function had been monitored with reasonable regularity and in accordance with the relevant requirements. Furthermore, the adviser did not have concerns about the medication prescribed to Mr C by the practice and concluded that there was no evidence that the practice had failed to adequately monitor Mr C's blood pressure or that their actions had contributed to reduced kidney function. We therefore did not uphold this aspect of Mr C's complaint.

Mr C also complained that the practice did not respond reasonably to his complaint. In response to our enquiries, the practice identified that some of the complaint correspondence did not meet a number of the requirements of the Patients Rights (Scotland) Act 2011. The practice told us that the practice manager had undertaken to fully familiarise themselves with the requirements of the Act and that they would update the practice's complaints procedure to reflect the requirements. Although we found that many aspects of the practice's handling of the complaint were reasonable, we were critical that the practice had not followed the guidance in relation to acknowledging complaints and updating complainants after a delay. We therefore upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the practice:

• apologise to Mr C for failing to handle his complaint in accordance with the relevant guidance; and
• provide this office with a copy of their updated complaints procedure.

Summary

Mr C complained about the care and treatment provided to his wife (Mrs A) at Raigmore Hospital. Mrs A needed surgery to dilate and place a stent (a tiny tube inserted into a blocked passageway to keep it open) in the artery in her chest supplying her left arm, to assist with her kidney dialysis. The board were unable to place the stent in a satisfactory position and carried out surgery to remove the stent. This caused internal bleeding and Mrs A was taken to theatre for emergency surgery. The surgery proved too much for Mrs A's vital organs and she died. Mr C raised several concerns about his wife's care and treatment by the board. These included that the board failed to give Mrs A appropriate explanations about the risk of the stent procedure and failed to obtain Mrs A's informed consent for the procedure.

We obtained independent medical advice from a consultant vascular and endovascular surgeon and a consultant interventional radiologist. The board said they did not advise Mrs A of the risk of death, as they consider it to be below the threshold required to be specifically mentioned as a complication. The radiologist adviser said that as Mrs A was unwell and suffered from heart failure and other conditions, the risk that any complication of the procedure would result in very serious consequences for Mrs A was increased. It would, therefore, have been reasonable for the board to have discussed the risk of death with Mrs A. We upheld this part of the complaint.

Both advisers said that the evidence suggested that the board failed to follow their consent procedure, as they only appear to have discussed the stent procedure with Mrs A on the day of the operation. Therefore, Mrs A would not have had adequate time to reflect on the surgical options. We therefore considered that the board failed to obtain Mrs A's informed consent for the procedure. We upheld this part of the complaint.

Recommendations

We recommended that the board:

• feed back our findings on explanation of the stent procedure and informed consent to the staff involved;
• provide us with evidence that a revised consent form has now been implemented;
• ensure that in future, they appropriately advise patients of the risk of death;
• ensure that in future, when they discuss surgical procedures with patients, they give them adequate time to reflect on the information provided before surgery is carried out; and
• provide Mr C with a written apology for the failings identified.

Summary

Mr C complained about the care and treatment provided to him at the diabetes clinic at the New Victoria Hospital. Mr C complained that when he was experiencing severe problems with his diabetes there were delays in him being given appointments, and that he was often given phone reviews instead of face-to-face appointments.

During our investigation we took independent advice from a diabetes nurse specialist. We found that Mr C had been reasonably assessed and offered appointments or phone reviews as appropriate. We found that over a period of six weeks he had eight phone reviews and two face-to-face appointments and we found that the advice and treatment given at each of these was reasonable. Therefore, we did not uphold these aspects of Mr C's complaint.

Mr C also complained about the phone service at the diabetes clinic. He said that often when he called he could not reach anybody to speak to and instead reached an answering service. We found that it was reasonable for the diabetes clinic to have an answering service as it was often the case that the nurses were unable to answer incoming calls as they were reviewing other patients. We did not uphold this aspect of Mr C's complaint.

Summary

Mr C was admitted to Queen Elizabeth University Hospital and diagnosed with atrial fibrillation (irregular and often rapid heartbeat). He was advised at this time that he would possibly need cardioversion (treatment to restore the normal heart rhythm) and that referrals would be made for him to have a scan of his heart and an out-patient appointment with a cardiologist. Mr C complained that it took eight months to receive treatment.

We took independent advice from a consultant cardiologist. We found that there were delays in Mr C receiving the scan, an out-patient appointment and treatment. We considered that the delays were unreasonable and failed to meet the Scottish Government's 18-week treatment time target.

Although we upheld Mr C's complaint, we did not consider that the delays would have affected Mr C's overall outcome. However, there would have been additional stress for Mr C in not knowing what was happening with his care.

Recommendations

We recommended that the board:

• apologise to Mr C for the delays that occurred in relation to his treatment plan after the diagnosis of atrial fibrillation; and
• take steps to ensure the problems which caused the delays do not recur and evidence the action they have taken to prevent them from recurring.

Summary

Mrs C complained about the care the board gave to her father (Mr A). Mr A had Parkinson's Disease and was admitted to Glasgow Royal Infirmary as he had fallen a few weeks before and had become confused and unable to cope at home. Mrs C said that shortly afterwards, he became constipated and was given an enema. She said that he was then left alone and when he attempted to go to the bathroom, he had fallen out of his bed which had the side rails raised. He broke his hip. Mrs C complained that if Mr A been properly assessed on arrival at hospital and properly supervised after the enema, he would not have broken his hip. She also complained that after the accident, he was not given appropriate physiotherapy treatment.

Mrs C complained to the board who agreed that there had been shortcomings with regard to Mr A's care. They said that a falls and bedrails assessment should have been carried out in a timely way and they should have ensured that Mr A understood the instructions he had been given about the enema. They apologised and put procedures in place to try to avoid the same thing happening in the future. However, with regard to physiotherapy, they said that as Mr A's condition had plateaued, it had come to an end.

We confirmed that there had been shortcomings in Mr A's assessments regarding falls, bedrails and cognitive condition. Although a comprehensive care plan was put in place, this should have been within 24 hours of Mr A's admission. Had this been the case, the risk of him falling may have been minimised or prevented. However, we further established that procedures with regard to the enema had been reasonable, as had Mr A's physiotherapy.

Recommendations

We recommended that the board:

• demonstrate to us the processes put in place as a result of Mrs C's complaint.

Summary

Mr C complained that his wife (Mrs A) underwent a number of surgical procedures for an anal fistula (an abnormal opening in the anus). He said that the procedures may have been unnecessary had staff at Inverclyde Royal Hospital identified that her high dose of Nicorandil (a medication used to treat angina) may have been the likely cause.

In responding to the complaint, the board acknowledged the possibility of a link between the Nicorandil and anal fistula, but said the only way to check was by stopping the medication to see if there were any improvements.

We took independent medical advice from a consultant colorectal surgeon. We found that although Nicorandil is known to cause mouth and rectal ulcerations when prescribed in higher doses, its association with anal fistula is much less clear. Therefore, given Mrs A did not present with ulceration, we considered it was reasonable that the surgeons involved in her care did not make the association between the anal fistula and Nicorandil. We concluded it was only with hindsight that the Nicorandil should have been stopped sooner.

Summary

Mr and Mrs C complained about the care and treatment provided to their daughter when she was delivered. At the time of, or shortly after, the delivery by forceps, she sustained a deep cut to her foot. The board were unable to provide an explanation for the cut. Mr and Mrs C complained that board staff failed to perform the forceps delivery in a reasonable manner, and that they subsequently failed to provide appropriate treatment for the injury.

During our investigation, we took independent advice from an obstetrician and a paediatrician. We found that the forceps delivery was not the cause of the cut and that the cut was most likely to have been sustained after the delivery. We did not uphold this aspect of Mr and Mrs C's complaint. Additionally, we found that the treatment given was timely and reasonable and, therefore, did not uphold this aspect of Mr and Mrs C's complaint.

Mr and Mrs C also complained about how the board handled their complaint. They said that the board had taken a long time to respond to their complaint and that they had not made efforts to contact all of the staff involved in the delivery. The board said they had initially not thought that the complaint was to be treated as such, and that they had confirmed this with Mr and Mrs C. However, they could not provide evidence of this being confirmed with Mr and Mrs C. We found this to be unreasonable. In addition, we found that the board could have made further efforts to contact staff involved in order to give a fuller explanation of events surrounding the cut. We also found that in recording the incident, the board had not made efforts to contact midwifery staff and we did not find this to be reasonable. Therefore, we upheld this aspect of Mr and Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise for the complaints handling failures identified by this investigation;
• feed back the findings of this investigation to the relevant complaints handling staff; and
• feed back the comments of the obstetrician adviser to the relevant staff.