Health

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.

Summary

Ms C had surgery for breast cancer in her right breast. She reported a lump in her breast 11 years later. Further tests were carried out at Forth Valley Royal Hospital but did not show evidence of cancer. Ms C was followed up with repeat tests which identified a local recurrence of cancer. Ms C then had a mastectomy (an operation to remove the breast), which showed no evidence of cancer. Later, a marker clip (a small titanium clip used to mark the site) initially placed at the time of the biopsy was removed along with surrounding tissue, which also did not show evidence of cancer.

Ms C complained that she should have undergone more tests and should have been reviewed every four weeks after the lump was identified. She also complained that the mastectomy may not have been required and had concerns about the lack of action taken in response to the marker clip that had not been removed at the time of the mastectomy.

We took independent medical advice from a consultant breast surgeon and a consultant radiologist. We did not find failings in Ms C's care and treatment before or after the mastectomy. We considered that she received appropriate tests and was reviewed within a reasonable timescale. In addition, given there was evidence of invasive cancer identified from a biopsy and Ms C's history of previous radiotherapy for breast cancer, we considered that the mastectomy was warranted. In terms of the marker clip, we found that there were no failings in relation to mastectomy technique and that reasonable steps were taken to remove it and check the surrounding tissue. We did not uphold Mrs C's complaint.

Summary

Mr C complained about an endoscopy procedure that he had undergone at Forth Valley Royal Hospital which he found painful. Mr C died while our investigation was ongoing. Mr C's death was not connected to the endoscopy procedure about which he complained.

After making further enquiries, we decided that the most appropriate course of action was to discontinue our investigation.

Summary

Mrs C was required to travel outwith the board area for treatment of a rare condition from which she suffers. She complained that the board's policy of reimbursing after travel, rather than paying upfront, caused her financial hardship. The board confirmed that it was their policy only to reimburse on production of receipts and Mrs C's request for upfront payment was refused. We were satisfied that the board acted in line with their documented procedure and we did not uphold the complaint.

However, the board acknowledged a need to consider exceptional circumstances on a case-by-case basis. They subsequently reviewed their procedure and established that other health boards have an ability to make payment in advance. They updated their procedure to include a provision for making upfront payments where exceptional circumstances are deemed to exist. We considered this action reasonable and had no further recommendations to make.

Mrs C raised further concerns that the board had refused to pay her the associated costs of travel, such as the cost of meals and childcare. We did not take this forward as the board's procedure clearly set out that only the costs of travel and accommodation are eligible for reimbursement. In addition, Mrs C complained that the board had communicated poorly with her and, while we noted there were occasions where they delayed in responding to her requests for information, we were satisfied that they had already explained, and apologised for, these delays.

Summary

An arrangement was in place whereby Mr C received his meals in his prison cell. This was as a result of the anxiety Mr C experienced in attending the prison dining hall due to post-traumatic stress disorder (PTSD). However, the board advised the Scottish Prison Service (SPS) that Mr C could return to the dining hall to have his meals. Mr C complained about the board's decision that he was fit to do so.

We took independent medical advice from a consultant forensic psychiatrist who noted that the in-cell dining arrangement did not appear to have been a significant feature of Mr C's historic clinical assessments. They also noted that there was no indication that PTSD was felt to have been a major ongoing issue for Mr C. They considered that Mr C was appropriately reviewed by clinicians before deciding that he was fit to attend the dining hall and that this decision was reasonable. We did not uphold the complaint.

However, the adviser considered that the psychiatrist who reviewed Mr C's fitness to attend the dining hall should have provided clearer and more definitive advice to the SPS. As they were still in training, they should have discussed the situation with their supervising consultant if they were unclear on what to advise. There was no evidence that this happened. We noted that the psychiatrist had indicated they would leave it for the SPS to make the final decision, rather than focusing on providing clear and specific advice upon which they could base their decision. We considered that the board's role in such decision-making could benefit from being clarified through the provision of guidance to mental health staff and we made recommendations accordingly.

Recommendations

We recommended that the board:

• take steps to ensure that any non-consultant-grade psychiatric staff providing input to the SPS are appropriately supervised;
• remind prison mental health staff to ensure that they provide clear and specific advice and/or recommendations to the SPS when they receive a reasonable request for clinical input into a decision; and
• consider introducing written guidance for prison mental health staff on dealing with requests from the SPS for clinical input into decisions relating to the management of prisoners, taking account of the psychiatric adviser's comments.

Summary

Ms C complained about care she received from her medical practice. When Ms C received a copy of her medical notes she found that during a previous consultation two years earlier, the GP had noted a mild vaginal prolapse and had not told her about this. Ms C complained that she should have been told about the prolapse and treated for it, and that the practice had not reasonably responded to her complaint.

We sought independent medical advice and found that while the failure to inform Ms C of this incidental finding had not caused significant harm to her, the GP should reflect on this decision further. We upheld this complaint.

However, the adviser's view was that the decision not to provide treatment at the time was reasonable, as was the response to Ms C's complaint. We therefore did not uphold this aspect of Ms C's complaint.

Recommendations

We recommended that the practice:

• reflect on the decision not to inform the patient of an incidental finding.

Summary

Miss C had been experiencing poor health over a number of months and made a suicide attempt by medication overdose. She contacted NHS 24 and was taken to University Hospital Ayr. Miss C's symptoms included slurred speech and problems with walking. Miss C was assessed by nursing, medical and psychiatric staff and was later discharged. The following day, she attended with the same symptoms and was again discharged home. The next day, Miss C's GP arranged for her to attend University Hospital Crosshouse. A scan confirmed Miss C had a brain tumour, which was subsequently operated on. Miss C complained that, despite her presenting symptoms, she was not properly assessed or treated when she attended at University Hospital Ayr.

We took independent advice from a specialist in emergency medicine. We found that at the initial admission, the focus of attention had been on the immediate presenting problems of Miss C's mental health and the effects of the overdose and that the assessment and treatment provided that day were appropriate and reasonable. The adviser said that in normal circumstances, the symptoms Miss C presented with on her second attendance at the hospital should have resulted in further investigation. In this case, however, the adviser noted that the doctors involved had felt it was likely that Miss C's presenting symptoms were related to the overdose the previous day and that it was reasonable that they reached this conclusion. Therefore, we concluded that the assessment was reasonable. We also reviewed Miss C's records and were satisfied that the treatment she received was appropriate. Therefore we did not uphold Miss C's complaint.

Summary

Mr C complained about the care and treatment he received for a diabetic foot ulcer. Mr C had been receiving treatment for diabetes-related foot problems for an extended period. Due to difficulties with recurrent infection and Mr C's difficulty in complying with his treatment programme, he was fitted with a special cast to protect the ulcer on his foot. Mr C complained that the cast had been too tight and had damaged his foot, resulting in the possible amputation of his toe.

The board said no injury had been noted to Mr C's toe prior to the removal of the cast. They suggested that the injury had taken place between the removal of the cast and a subsequent medical review. The board said that the cast had been appropriately applied and reviewed and that the care and treatment had been of a reasonable standard.

We sought independent medical advice and found that Mr C's cast had been an appropriate course of treatment. There was no evidence that it had been incorrectly applied, or that it had damaged Mr C's foot. There was no record of a wound to Mr C's toe when the cast was removed. Mr C's medical review following removal of the foot cast did not attribute the injury to the cast. We also found that Mr C's ulcer had reduced whilst the cast was on his foot, demonstrating that the treatment had worked as planned.

We found that Mr C's care and treatment had been of a reasonable standard. The cast to his foot had been applied and removed by an appropriate specialist and there was no evidence to link the injury to his toe to the cast.