Health

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mrs A) that there had been an unreasonable delay in diagnosing that Mrs A's husband (Mr A) had cancer. Mr A had been admitted to the Southern General Hospital with breathlessness and swelling in his right leg. His condition deteriorated over the next few weeks and a number of tests were carried out. One month after he was admitted to hospital, it was confirmed that Mr A had metastatic cancer (cancer that spreads to other parts of the body).

We took independent advice from a consultant respiratory physician. We found that although the speed of investigation was timely during the first three days of Mr A's admission, there was then an unreasonable delay in carrying out further investigations and medical staff had not acted in line with the relevant guidance. An earlier diagnosis would have meant that Mr A and his family would have known the prognosis and likely outcome earlier. Palliative care could also have been considered at an earlier stage, although we found that curative systemic treatment (treatment such as chemotherapy that reaches cells throughout the body by travelling through the bloodstream) would not have been appropriate for Mr A. We upheld this aspect of Ms C's complaint.

Ms C also complained that staff had failed to ensure that Mr A had appropriate pain management. We found that although there was a good record of pain assessment within the nursing notes, there were numerous inconsistencies between the nursing and prescription records. We found that the pain management and escalation of pain relief treatment had not been in line with the relevant guidance and, in view of this, we also upheld this aspect of Ms C's complaint.

Recommendations

We recommended that the board:

• provide this office with an action plan detailing the steps that will be taken to prevent similar failings in future cases and to ensure that staff act in line with the relevant guidance;
• provide evidence that steps have been taken to ensure the involvement of palliative care specialist services at the appropriate stage in cases of this nature; and
• issue a written apology to Mrs A for the failings identified.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mrs A). Mrs A's husband (Mr A) underwent surgery at Glasgow Western Infirmary to repair an abdominal aortic aneurysm (a swelling of the main blood vessel that leads away from the heart which, when enlarged, can burst and cause fatal internal bleeding). Mr A's surgery was successful, however he later had to undergo a further operation to address a complication he suffered. This second surgery was also successful. Two days later Mr A had a sudden cardiac arrest and died. This was the result of a pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs) from a deep vein thrombosis (DVT - a blood clot in a vein). Ms C asked us to investigate Mrs A's concerns about the medical treatment that Mr A received during the original operation to repair the aneurysm and the risks of DVT.

We took independent advice from a consultant vascular surgeon and found that Mr A suffered an uncommon but recognised complication of his initial surgery, and that this had been dealt with appropriately. The adviser did not consider there to have been any unreasonable failing in the medical treatment provided. In relation to the prevention of DVT, the advice we received highlighted that there had been a reasonable assessment of risk and that preventative measures appropriate to Mr A had been taken. We did not uphold the complaint.

Summary

Mrs C complained that her child (baby A) had been incorrectly treated for tongue tie at Glasgow Royal Infirmary. Tongue tie is a problem affecting some babies with a tight piece of skin between the underside of their tongue and the floor of their mouth. Mrs C also complained that medical staff had provided her with inaccurate advice about her child's care and treatment. Mrs C said that in response to her complaint, medical staff had given misleading accounts of a consultation and a subsequent phone conversation. She also said that she had been denied a second opinion.

We took independent advice from a specialist in surgery for children, who found that baby A had been provided with the appropriate care and treatment. The adviser found that baby A had been referred for a second opinion to a specialist in this type of surgery. We were also advised that the appropriate surgery had been performed and that staff had appropriately suggested that baby A's health visitor make a further referral to Speech and Language Therapy services.

We found there was no evidence that staff had deliberately misrepresented their interactions with Mrs C. We found that the care and treatment was appropriate and that baby A had been referred for a second opinion.

Summary

Mrs C complained about a delay in receiving surgery. She said that she had waited longer than the 12-week treatment time guarantee (TTG) to be given a surgery date, and that this affected her quality of life as she could not work and had distressing ongoing symptoms. Mrs C also raised concerns about the board's handling of her complaint.

During the investigation of Mrs C's complaint, she was given a surgery date with the surgery taking place about 18 weeks after she agreed to the treatment. The board said the time-frame was due to the complexity of the surgery which meant that two different specialists had to be involved.

The board also said that Mrs C requested a named consultant, which Mrs C disputed. When we asked for evidence, the board acknowledged that this was incorrect and explained that staff had misunderstood the process and created a letter stating that Mrs C wished to have a named consultant, instead of the letter explaining that the TTG would not be met.

After taking independent medical advice, we upheld Mrs C's complaint about the delay. Although there was evidence that individual clinicians were aware of delays with this kind of surgery and were taking appropriate action, we were critical that the board did not deliver the TTG in Mrs C's case. We were also critical that the board did not contact Mrs C to explain the delay due to the administrative error. During our investigation we also found that a referral for further investigations had been missed due to the wrong name being given on the letter. Although the medical adviser said it was reasonable in this case for the surgery to go ahead despite these investigations not being done, we were critical that the referral was missed.

We were also critical of the board's handling of Mrs C's complaint as it appeared that the initial complaint, which was made by her mother, was missed by complaints handling staff which lead to a delay in it being investigated. However, instead of acknowledging this error, the board incorrectly said the delay was due to waiting for Mrs C to consent to the complaint.

Recommendations

We recommended that the board:

• feed back the findings of this report on the misdirected referral to the medical staff involved;
• review the arrangements for referrals of this kind to reduce the risk of referrals being misdirected in future;
• demonstrate to this office that a long-term solution has now been put in place to progress waiting lists for this kind of surgery;
• apologise to Mrs C for the failings identified; and
• discuss the findings of this report with relevant complaints handling staff for reflection and learning.

Summary

Mrs C complained about the care and treatment her mother (Mrs A) received in the Glen O'Dee Hospital following a hip operation. The initial plan was for Mrs A to return to her own home following physiotherapy, but after a fall she said she wanted to be discharged into a care home. Mrs C complained that after the fall, staff at the hospital failed to recognise that a screw in Mrs A's hip had become displaced and that a further fall was not recorded in Mrs A's records. Mrs C also said that communication with her and her mother was inadequate and that the board failed to take her views into account when reaching a decision to discharge Mrs A into a care home.

We took independent advice from a physiotherapist, a GP and a nursing adviser. We found that after her fall, Mrs A's physiotherapy treatment continued and she said she was not experiencing any pain. It was only when Mrs A began to feel pain that the situation was brought to the attention of a doctor who referred her to another hospital where she was x-rayed and the displaced screw was diagnosed. While Mrs C believed that there had been a subsequent fall, we found no evidence of this. However, we found that communication between the hospital and Mrs C had been poor as she had not been alerted to the fact that her mother had experienced a fall and we upheld this part of the complaint.

However, we also found that Mrs A had been quite definite in wishing to be discharged to a care home despite her daughter's wishes. While the board took Mrs C's wishes into account, Mrs A had capacity to make her own decisions and the board had to acknowledge this. It was only later that Mrs A changed her mind and agreed to be discharged to Mrs C's home. We did not uphold this complaint.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings identified in this report; and
• ensure that the nursing staff concerned are fully aware of their responsibilities regarding communication under the relevant section of the Nursing and Midwifery Council Code.

Summary

Mr A had lung cancer and was receiving end of life care at home. Mr A's wife (Mrs C) complained to us about the care he received from district nursing staff, about the standard of communication, and about the board's response to her complaints.

Mrs C was concerned about a dose of medication given to Mr A by the nurses and about record-keeping. We took independent advice from a nursing adviser and a medical adviser. They found that there was no evidence that the standard of record-keeping affected the management of Mr A's symptoms. They also found no error in the prescription or administration of the medicine. We did not uphold these aspects of Mrs C's complaint.

Mrs C also complained about a decision to move Mr A in bed. She said that this caused him pain and was concerned that a bathroom towel was used. We found that moving Mr A in bed was a good way of assessing pain control and that both the decision to move Mr A and the way he was moved were reasonable.

Mrs C complained that she had not received a good standard of communication from the nurses. The nursing adviser said that Mrs C had not been offered support and there was no evidence that staff had listened to Mrs C's concerns. However, given the available evidence, it was not possible to reach a judgement on other aspects of Mrs C's complaint about communication.

Mrs C also said that the board failed to respond reasonably to her complaints and that their response was accusatory. We found that while the board's response addressed every clinical issue, there was no evidence of compassion or empathy. We therefore upheld this aspect of Mrs C's complaint.

Recommendations

We recommended that the board:

• bring the failings in complaints handling to the attention of relevant staff and review their processes to ensure sensitive and appropriate responses to complaints; and
• apologise for the failings this investigation identified.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of Ms A that during a surgical procedure at Aberdeen Royal Infirmary to address a condition affecting her spine, Ms A's spinal-cord was injured which led to a significant deterioration of her condition. Ms C complained that staff failed to investigate her new symptoms following the procedure and that they failed to recognise that they were a result of an injury from the surgery.

We took independent medical advice from a specialist in neurosurgery. We found that while the evidence indicated the operation itself was carried out to a reasonable standard and that the cord injury Ms A suffered from was a recognised complication (and one which she had been made aware of prior to the operation), there were shortcomings. Firstly, there was no evidence that clinicians had discussed all treatment options with Ms A during the consent process. Secondly, clinicians unreasonably failed to investigate Ms A's new symptoms before discharge home. Therefore, we upheld Ms C's complaint.

Recommendations

We recommended that the board:

• take steps to ensure clinicians discuss all relevant treatment options with patients during the consent process and document this;
• bring the failings identified in this investigation to the attention of relevant staff; and
• apologise for the failings identified in this investigation.

Summary

Mrs C underwent cataract surgery to her right eye at the Golden Jubilee National Hospital and had no concerns. However, she then complained about the care and treatment she received following subsequent cataract surgery to her left eye because she was experiencing pain and double vision. Mrs C was concerned that she was not informed prior to the operation that a different doctor would be performing the second surgery, that her left eye was not properly anaesthetised, and about the lack of treatment after she raised her concerns, post-surgery.

We took independent medical advice and found that it was reasonable for a different doctor to have performed the second surgery. However, we found that it should have been properly explained to Mrs C when she consented to the surgery that it could be a different doctor. In addition, we found that the consent form did not clearly state all of the known risks and complications of her surgery, which would have been accepted good practice. There was documentation indicating that some form of conversation took place with Mrs C about the risks of post-operative inflammation and the possibility that further surgery might be needed. However, we were critical that it was not clearly completed and recommended the board take further action to address these two issues relating to the consent process.

However, we did not uphold Mrs C's complaint on the basis that there was no definitive evidence to support that there was a problem with the anaesthetic or the operation itself. There was a small amount of plaque left behind but we considered it was reasonable not to remove it due to there being an increased risk of complications if removed.

We considered that it was reasonable for Mrs C to be discharged to the care of her optician after the operation. We noted that the optician referred Mrs C to a different hospital when she experienced pain and inflammation in her left eye, and that the care plan was to carry out further surgery. We considered it was appropriate for the board to advise Mrs C to continue with this suggested care plan. Whilst we did not uphold Mrs C's complaint, we were critical that there was no evidence to clearly show that the operative findings had been explained to Mrs C or her optician and that as a result of these findings she may develop inflammation and require further surgery. We therefore made recommendations to address these communication problems.

Recommendations

We recommended that the board:

• share the findings of this investigation in relation to the consent process with staff concerned;
• consider amending their consent form to include a separate section for listing all the relevant risks and complications discussed with the patient;
• draw to the attention of the doctor who carried out the second surgery the importance of sharing the operative findings and potential for further surgery with both Mrs C and the optician who managed her post-operative care; and
• apologise to Mrs C for the failings identified in this investigation.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of Mr B regarding the care and treatment provided to Mr B's father (Mr A) during his admission to Forth Valley Royal Hospital. Ms C complained that Mr A's falls risk was not appropriately assessed on two different wards, that the nursing care provided to him was not reasonable, and that staff attitude and communication with Mr A's family was unreasonable.

During our investigation, we obtained independent advice from a nursing adviser. We found that whilst Mr A's assessment and care in relation to falls on the first ward he stayed on was reasonable, on the second ward his levels of confusion were not taken into account when assessing the risk of falls. We considered this to be unreasonable. We also found that whilst the nursing care provided to Mr A was reasonable in terms of personal care and administration of medication, the nursing care plans had not taken into account Mr A's need for emotional support. We also found that the use of bedrails for Mr A had been inconsistent. We did not consider this to be reasonable and upheld this complaint. In terms of staff attitude and communication with Mr A's family, we found that communication had often been unplanned and ineffectively co-ordinated, but that this was often due to short-notice changes to plans for Mr A given his fluctuating physical state. We considered that a planned approach to communication may have been beneficial, but that there was no evidence of unreasonable staff attitude towards the family. We made several recommendations to the board to address the failings identified.

Recommendations

We recommended that the board:

• take steps to ensure that the impact of cognitive impairment on patient safety on the relevant ward is appropriately assessed and that measures to minimise harm are a prominent aspect of care plans;
• apologise to Mr B for the failings identified in relation to the falls assessment and care provided to Mr A;
• take steps to ensure recording and use of bedrails is consistent;
• take steps to ensure that emotional support is identified as a care need and planned for where appropriate;
• apologise to Mr B for the failings identified in relation to the nursing care provided to Mr A; and
• consider whether a planned approach to communication, agreed between patients' families and staff, should be put in place.

Summary

Mrs C complained that over a 12-month period, two doctors at her medical practice failed to provide her with appropriate clinical treatment for her back. Mrs C said that when an MRI scan was eventually arranged, this showed that she had a tumour on her spinal cord which she had surgery to remove.

Mrs C said the two doctors at the practice failed to listen to her when she explained her ongoing symptoms and asked for help, failed to undertake appropriate assessments and investigations, and failed to arrange appropriate specialist referrals.

We took independent medical advice and found that the two doctors communicated reasonably with Mrs C, undertook appropriate assessments, investigations and referrals and provided her with appropriate treatments based on her clinical symptoms at the time. We found that the doctors followed the Scottish Government back pain guidelines and the Healthcare Improvement Scotland referral guidelines for suspected cancer and said that the care Mrs C received was of a reasonable standard. The adviser also explained that GPs could not arrange referrals for MRI scans and that such scans could only be requested by a physiotherapist or a hospital specialist. We therefore concluded that the doctors did not fail to provide Mrs C with appropriate clinical treatment in view of her reported symptoms and we did not uphold her complaint.