Health

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.

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.