Health

Summary

Mrs C complained about the care and treatment she received when she gave birth at Dumfries and Galloway Royal Infirmary. In particular, she said that a pessary used to induce labour was left in too long, she was unable to use the birthing pool and a tear she suffered was not effectively repaired.

We took independent midwifery advice and found that overall, Mrs C's labour and birth had been conducted reasonably. The pessary had been used appropriately and was removed as labour progressed. Stitching of the tear she sustained was completed quickly and though it was recognised that sutures could become loose, Mrs C was referred to an obstetrician as required.

However, it was noted that Mrs C either did not receive or did not understand information given about anaesthetic and how its use had repercussions with regard to the use of the birthing pool. Furthermore the clinical records, which were not of the standard required by current guidance, lacked information. For these reasons, we upheld Mrs C's complaint.

Mrs C also complained about her aftercare. However, we found no evidence to show that this had not been reasonable.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failures identified in this investigation; and
• ensure that relevant nursing staff are reminded of their obligations with regard to guidance on record-keeping.

Summary

Mr C complained on behalf of his late father (Mr A). He raised concerns that staff at Dumfries and Galloway Royal Infirmary failed to provide Mr A with appropriate medical treatment and about the board's handling of his complaint.

Mr A attended the hospital for a hernia operation. The operation was performed and Mr A was discharged. However, Mr A became unwell and was readmitted to hospital the same day. Mr A's condition continued to deteriorate and he died some months after the operation. The board conducted a significant adverse event review (SAER) and complaints investigation. These processes identified a number of failings, including an error in the prescription of bisoprolol (a beta-blocker, used to treat high blood pressure) and a failure to review blood tests.

Mr C questioned whether the board had appropriately identified all the issues in Mr A's care and whether they had appropriately taken action to address these failings. In addition to the issues with the medication and the review of blood tests, Mr C raised concerns about monitoring Mr C's fluid levels, attending to his catheter and the actions of the consultant surgeon and anaesthetist prior to and after Mr A's admission, including whether staff should have undertaken the operation. Mr C also raised concerns about the way the board's investigations had been conducted, including the interaction between the two processes and delays in responding to his correspondence.

After receiving independent advice from a consultant in general medicine and a nurse, we upheld Mr C's complaints. We found that the prescription of bisoprolol was unreasonable. We also found the board failed to review Mr C's blood tests. We found the board had subsequently taken appropriate action in relation to these issues. However, we also found there was a lack of specific medical review prior to Mr A's discharge and we were critical of this aspect of Mr A's care. We also found failings in respect of monitoring Mr A and in attending to his catheter. In relation to the decision to proceed with Mr A's operation, we found that Mr A had given his informed consent to the procedure, and as Mr A had capacity to make this decision, it was appropriate to proceed with the operation.

We also found that the board's handling of Mr C's complaint was unreasonable. In particular, we found there was confusion about the interaction between the SAER and the complaints process, which lengthened the process and resulted in significant errors in communication with Mr C.

Recommendations

We recommended that the board:

• take steps to ensure the clinician responsible for the error in giving Mr A his heart medication is made aware of the findings of this investigation for reflection and learning;
• confirm that the consultant surgeon will discuss this case in their appraisal;
• provide this office with a progress report on the actions taken to address the issues in the case, including catheter care;
• apologise for the clinical failings identified in this investigation;
• take steps to ensure that staff explain to complainants how the SAER and complaints handling processes are being taken forward in each case;
• feed back the findings of the investigation to the relevant staff for reflection and learning; and
• apologise to Mr C for the failures in complaints handling.

Summary

Miss C, an advocacy and support worker, complained on behalf of Mr A about the care and treatment he received at Dumfries and Galloway Royal Infirmary for the surgical removal of haemorrhoids. Mr A developed a wound infection (a recognised complication of surgery) and he had to have a permanent colostomy. Miss C complained that Mr A had not been fully informed about the risks of the surgery, that his operation was not performed properly, and that care of his wound was poor.

We took independent advice from a general and colorectal surgeon. We found evidence to support that the surgery carried out was to a reasonable standard. However, Mr A reattended the hospital by ambulance with post-operation wound-related problems and we considered that the registrar doctor who reviewed Mr A at this point should have contacted the surgeon who had carried out the surgery or the consultant surgeon responsible for admissions that day. We therefore upheld this aspect of Miss C's complaint.

We also took independent advice from a nursing adviser and found evidence of appropriate care of Mr A's wound following surgery. We were critical that a full nursing assessment was not carried out at the time Mr A re-attended hospital. However, we did not consider this to have been a failing by the nurses, due to Mr A having been discharged.

We found insufficient evidence to show which risks and complications of surgery had been discussed with Mr A prior to him consenting to the operation. We were also critical that the consent form did not include all of the known risks and complications of the surgery. We therefore upheld this aspect of Miss C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr A for the failings identified;
• demonstrate there is an effective process in place to ensure review takes place with the operating consultant or, if unavailable, the consultant surgeon with responsibility for acute surgical receiving when post-operative patients re-present to the emergency department;
• ensure the speciality doctor reflects on the findings of this investigation at their annual appraisal as part of shared learning and improvement;
• review their consent process to ensure that all risks and complications relevant to surgery are fully documented, that they have been discussed with the patient and that written patient information has been provided where relevant; and
• draw these findings to the attention of the consultant surgeon and the trainee doctor who completed the consent form.

Summary

Mr C complained that staff at University Hospital Ayr failed to provide him with appropriate clinical treatment, based on the symptoms he reported.

Mr C experienced pain in his back and dropped foot (a muscular weakness that makes it difficult to lift the front part of the foot and toes). Mr C's GP arranged for him to attend A&E and he was seen by members of the hospital's orthopaedic team. A diagnosis was made of a prolapsed intervertebral disc (ruptured disc in the spine) with associated motor weakness. The decision was made not to treat Mr C surgically at that time. An MRI scan was also considered to be unnecessary. Mr C was referred to his GP to arrange physiotherapy and he saw a physiotherapist some days later. Based on Mr C's symptoms, he was then referred to hospital and received an MRI scan and an emergency operation.

After receiving independent advice from an orthopaedic surgeon, we did not uphold Mr C's complaint. We found that an examination of Mr C at A&E did not reveal red flag features (features which would have required urgent intervention). In this context, we found that the plan of management without surgery adopted at A&E was appropriate. We therefore did not uphold Mr C's complaint.

Summary

Ms C, an advocacy and support worker, complained on behalf of Mr A about the care and treatment he received from the orthopaedic and physiotherapy departments at Ninewells Hospital after he fractured his fibula (shin bone). Mr A was unhappy that he was not given surgery at this time and that he was only discharged with crutches and pain relief with no follow-up appointment. Mr A continued to experience pain and self-referred to physiotherapy, which did not help his pain. He was dissatisfied that the physiotherapist did not query why his leg was not improving and he felt there was a missed opportunity to identify the lack of healing.

We took independent advice from two clinical advisers on the care and treatment Mr A received. We found that the orthopaedic care was reasonable and in keeping with this type of fracture. In addition, there was evidence that appropriate advice was given at the time Mr A was discharged from hospital. Although a follow-up appointment was not felt to be necessary, Mr A was informed at the time of discharge that he could contact the fracture clinic if he experienced any problems, which he did. We found that he was reviewed further and that the decision to continue conservative (non-surgical) management was appropriate. However, we were critical that there was poor communication between the orthopaedic ward staff and physiotherapy department prior to Mr A's discharge from hospital which meant that he was not reviewed by a physiotherapist. The board had apologised to Mr A but we made a further recommendation to ensure the matter does not recur.

We were also critical that the physiotherapy care Mr A received as an out-patient failed to document relevant factors in order to properly assess his calf pain. Therefore we upheld this complaint.

Recommendations

We recommended that the board:

• inform us of the mechanisms in place to ensure effective communication between orthopaedic ward staff and the physiotherapy departments;
• ensure the physiotherapists involved in Mr A's care clearly record a patient's primary problem, a full subjective and objective patient history and the measurable outcomes; and
• apologise to Mr A for the failings identified in relation to the outpatient care he received for his calf pain.

Summary

Mr C attended the chest clinic at Ninewells Hospital with shortness of breath. He said that he was told by the doctor at the clinic that he would be referred for an echocardiogram (a scan used to look at the heart and nearby blood vessels) and an exercise test and that it would be four to six weeks until the tests were carried out. Mr C said that when he phoned the board four weeks later, he was told there was a 28-week waiting time for the echocardiogram/exercise test from date of referral.

Having complained to the board about the delay and received no response, Mr C arranged to have the echocardiogram/exercise test done privately and it was carried out that month. Mr C said that two weeks after the test, the board advised him that he would be given an appointment for the test in two weeks' time. Mr C said that had he known this he would not have arranged the test himself. Mr C also complained that the board unreasonably refused to pay the costs of the test he obtained privately.

We obtained independent medical advice on the complaint from a consultant physician in respiratory and general medicine. The adviser said that in Mr C's case, the echocardiogram and exercise tests would be considered routine, rather than urgent. The adviser said the original waiting time given by the doctor of four to six weeks would have been given in good faith and as the test would be provided outwith his own department, they would probably not have been aware of the actual wait. The adviser said a 28-week wait for the test was undesirable but was an unfortunate consequence of resourcing issues at the board.

Whilst it was understandable that Mr C was anxious to determine the cause of his symptoms and therefore arranged for the tests to be done privately, we considered it was not unreasonable for the board to refuse to pay the costs of Mr C's private treatment.

Summary

Mrs C complained that her husband (Mr A) had received inadequate nursing care and treatment when he was a patient at Perth Royal Infirmary. Mr A had a number of health problems including diabetes and had previously had a toe amputated. He then had a major stroke and was transferred to the hospital for rehabilitation.

We took independent nursing advice on the complaint. We upheld Mrs C's complaint as we found that staff had initially failed to dress Mr A's toe amputation wound when he was admitted to the hospital. They had also failed to ensure that his feeding tube (a tube passed through the abdominal wall) was regularly flushed. In addition, nursing staff had failed to inform both Mrs C and the vascular nurse of a wound on one of Mr A's other toes. However, we were satisfied that the board had apologised to Mrs C for the failings in Mr A's care.

Mrs C also complained to us that staff had failed to ensure that suitable arrangements were in place when Mr A was discharged. We found that the discharge planning had been reasonable and we did not uphold this aspect of her complaint.

We upheld Mrs C's complaint that staff had failed to respond appropriately to her verbal complaints. The board had already accepted that complaints she made to staff in the hospital could have been dealt with more effectively and appropriately at the time. They had told Mrs C that they would review the complaints awareness training needs of frontline staff and had apologised to her for the events she had described.

Recommendations

We recommended that the board:

• take steps to ensure that education and training on wound care has been provided to support workers in the hospital; and
• consider reviewing their policy on the care and management of tube feeding.

Summary

Mr C complained that the board delayed in giving him his cardiac medication after he was admitted to prison. Mr C had a heart attack two days later and required surgical treatment. He was unhappy that the board withheld the medication he had in his possession at the time of admission to prison.

The board accepted that it had taken 24 hours longer than it should have done to verify and prescribe Mr C's medication. They apologised to Mr C and advised him of the steps they had taken as a result of the incident to reduce the likelihood of it recurring.

We took independent advice from one of our GP advisers and found that it was appropriate for the board to confirm Mr C's prescribed medication in line with General Medical Council guidance. However, we were critical that there was an unreasonable delay in this being done, although it was unlikely to have caused Mr C's heart attack.

Whilst we upheld the complaint, we made no recommendations as the board had taken reasonable action as a result of the incident to identify learning and improve their practice to ensure the matter would not recur.

Summary

Ms C's partner (Mr A) collapsed. He was treated by a paramedic and transported to hospital, where he later died. Ms C complained that Mr A's mobile phone went missing.

Our investigation focused on the actions taken by the Scottish Ambulance Service to locate the phone or to try to find out what happened to it. Although they did not find the phone, we were satisfied that reasonable efforts were made to investigate this matter.

Summary

Mr C complained about the time it took for the Scottish Ambulance Service to send an ambulance after he and his wife (Mrs C) were involved in a road traffic collision. It took 40 minutes for the ambulance to arrive and Mr C felt that the ambulance service should have contacted either off-duty staff or trained responders to assist his wife, who was in pain.

We found that the ambulance service had acknowledged from the outset that there had been a delay in the ambulance being dispatched. We considered the ambulance service had acted in accordance with their call-out procedures in relation to off-duty staff and trained responders (including GPs) because there was no apparent threat to life.

The ambulance service provided information on the action they took as a result of the delay. They have reviewed their shift capacity and put further measures in place including the training of staff and new posts.

In terms of the ambulance service's handling of Mr C's complaint, we considered that there was an unreasonable delay of around six months in responding to additional questions Mr C had asked. The ambulance service accepted that there were failings in relation to the time they took to reply to Mr C. Therefore they introduced a pilot method to record contact from individuals as part of their complaints handling.

Recommendations

We recommended that the ambulance service:

• apologise to Mr and Mrs C for the delay in dispatching an ambulance and the delay in responding to the additional questions Mr C raised as part of his complaint; and
• provide documentary evidence on the outcome of the pilot they conducted in order to ensure appropriate steps have been taken to address the failings in relation to record-keeping and responding to complaints correspondence.