Health

Summary

Mr C was referred to the ear nose and throat (ENT) department at the board by his GP following symptoms of hoarseness. He was examined at an out-patient appointment where no sinister findings were identified and was discharged back into the care of his GP. Mr C's symptoms persisted and his GP made a further ENT referral. This was assessed by a consultant who made a referral to speech and language therapy (SALT). Mr C was seen at a SALT out-patient appointment some time later and potential malignancy was identified in his voice box. An appointment with an ENT consultant was arranged for the following day. Mr C was subsequently diagnosed with cancer and underwent surgery to remove his voice box. Mr C complained that a proper examination had not been carried out during his initial appointment, that it was inappropriate to refer him to SALT following the further referral from his GP and that there was an unreasonable delay in offering him an ENT appointment following the further GP referral.

After taking independent advice from an adviser, who is a consultant surgeon specialising in head and neck cancers, we did not uphold Mr C's complaints. The advice we received was that all necessary examinations had been carried out during the initial appointment and that it was appropriate to refer Mr C to SALT following the further referral from his GP. We found that there was no reference in the ENT consultant's referral to SALT for follow-up after the assessment but noted that Mr C had had an ENT consultation the next day in any case. We made a recommendation to the board to draw the adviser's comments on this to the attention of the ENT consultant.

Recommendations

We recommended that the board:

• make the relevant consultant aware of the adviser's comments on ENT follow-up following SALT referrals and recording neck examinations.

Summary

Mrs C complained about the care and treatment provided to a resident (Mr A) of the care home she managed when he was admitted to Glasgow Western Infirmary to have a catheter fitted. Mr A had dementia. Medical staff had to make a number of attempts to fit the catheter, which distressed Mr A. Mrs C said that staff failed to provide adequate care when they attempted to insert a catheter and properly manage his pain. She also said that staff failed to provide Mr A with adequate sustenance and communicate with his carer as they should have done.

We took independent advice from a nursing adviser. We found that the board failed to provide Mr A with adequate sustenance or communicate with his carer as they should have done, particularly given Mr A's dementia. However, we found no evidence that the placement of a catheter was unreasonable (although we appreciated how distressing an experience this was for Mr A) or that staff had failed to manage his pain.

Recommendations

We recommended that the board:

• consider and report on steps taken to address the failings we identified;
• bring the nursing adviser's comments about communication to the attention of relevant staff; and
• apologise for the failures we identified.

Summary

Mrs C complained about the treatment her mother (Mrs A) received from the practice. Mrs A had been unwell with cold/flu-like symptoms and a sore chest. She was prescribed antibiotics and advised to return if there was no improvement so that a chest x-ray could be arranged. Mrs A returned a few days later as she was still unwell. No shortness of breath or chest pain was noted and Mrs A was sent for a chest x-ray. The next day, Mrs A requested a home visit but was asked to attend at the practice following a phone conversation with a doctor. During the consultation, Mrs A collapsed. Cardiopulmonary resuscitation (CPR) was started and an ambulance was called but Mrs A died. Later, the family had difficulties in arranging a time to speak with a doctor about what had happened. Mrs C complained about the clinical treatment that was provided as she considered there was a failure to diagnose Mrs A's heart attack or take appropriate action. She also complained that the practice had failed to communicate adequately following Mrs A's death.

After taking independent advice from one of our medical advisers, who is a GP, we did not uphold Mrs C's complaint about the treatment provided. The adviser considered that the standard of care provided to Mrs A was reasonable and that practice staff had tried to resuscitate her to the best of their ability. We found that there is no formal requirement for practices to have a defibrillator available and that defibrillation would not have saved Mrs A's life. However, we did make a recommendation that the practice consider obtaining a defibrillator.

We found the practice had acknowledged failings in their communication with the family and had apologised for this. We noted that their protocol had been updated to prevent a recurrence of such an error in future. We upheld this element of Mrs C's complaint, but in light of the action already taken by the practice, we did not make any recommendations about this.

Recommendations

We recommended that the practice:

• consider obtaining access to a defibrillator for use in emergency situations.

Summary

Mr C complained to us about the care and treatment he received from Stobhill Hospital when he had a circumcision operation. He complained that he had received poor treatment from nursing staff immediately after his operation. When he developed an infection in the wound, he sought specialist input. However, he complained that the surgeon did not examine him properly and dismissed his concerns. He returned to the same surgeon two more times over the following year, and was told that the wound had healed and nothing could be done to improve his discomfort. Mr C was then referred to a different surgeon who identified an issue with the way the scar had healed. He had another procedure which corrected this problem. Mr C said this should have been identified earlier. He also raised concerns about the way his complaint was handled.

We took independent advice from a nursing adviser and an adviser specialising in urology (relating to the urinary system and male reproductive system). They reviewed the care and treatment Mr C had received. The urology adviser noted that there was very little evidence that Mr C had been appropriately informed of the risks involved in the procedure prior to providing consent. However, he was satisfied that the operation was conducted appropriately, and that the follow-up consultations were reasonable. He said that the differences in the conclusions of the two surgeons related to their professional opinions about the scar, and this was reasonable. The nursing adviser was satisfied that nurses had monitored Mr C appropriately after his operation, and noted that the concerns he raised were not evident from his medical records.

We concluded that, while Mr C's operation had been reasonable, it appeared that he was not given enough information to provide informed consent, so the procedure was not conducted appropriately. We were satisfied that Mr C's subsequent examinations were reasonable. However, we found that the board had not provided a reasonable response when Mr C first raised concerns. When he persisted with his complaint, the board then took too long in providing a final response.

Recommendations

We recommended that the board:

• consider revising their leaflet for patients having circumcision taking into account the guidance from the British Association of Urological Surgeons and the Royal College of Surgeons;
• take steps to ensure adequate information is provided on the risks and potential complications of this procedure at an appropriate time prior to any decision being made to proceed with it, and that this is recorded;
• feed back the findings of this investigation to relevant staff; and
• apologise to Mr C for the failings identified.

Summary

Mrs C complained about the care her daughter (Miss A) received from Parkhead Hospital for anorexia nervosa. Mrs C was dissatisfied that Miss A lost weight in hospital and was not given enough calories. She said that the re-feeding plan was not tailored to meet Miss A's needs and that staff did not respond properly to the concerns she raised at the time of the hospital admission.

We took independent advice on this case from two of our advisers experienced in working with patients who have eating disorders, one of whom is a dietician and the other a mental health nurse. We found that there was an appropriate re-feeding plan and measures in place which were in line with national guidance. However, for approximately two weeks, Miss A's calorie intake was not in accordance with the re-feeding plan which the board acknowledged and apologised for. We also identified that the records made by the nursing staff should have been more detailed, and that there was insufficient historical information documented about Miss A's background and whether any psychological therapies had been offered to her or the family.

We considered that there was evidence to show that staff had listened to concerns raised by the family about Miss A's preference to have liquid nutritional supplements instead of solid food. Furthermore, an agreement had been reached for Miss A to follow the re-feeding plan rather than have a feeding tube put in place.

Recommendations

We recommended that the board:

• ensure their re-feeding policy includes guidance on offering psychological therapies and support to patients and their families; and
• draw to the attention of nursing staff involved in Miss A's care the importance of documenting relevant information related to a patient's behaviours, weight and family background.

Summary

Mr C's daughter (Ms A) gave birth to a baby boy. Her pregnancy had been normal until the 32nd week when her blood pressure was noted to be high. She was monitored for pre-eclampsia (a pregnancy-related condition involving a combination of raised blood pressure and protein in the urine). Following the birth, Ms A suffered episodes of diarrhoea. This appeared to resolve and she was discharged home with her new baby. Midwives visited her at home over the following days and noted that she had had further episodes of sickness and diarrhoea, but again these were noted to have resolved.

Nine days after the birth, Ms A advised the attending midwife that she was unwell with tiredness, light-headedness, diarrhoea and vomiting. The midwife also recorded concerns about the baby's weight. Whilst arrangements were made for the baby to go back into hospital for checks, Ms A advised that she would attend her GP. Ms A became increasingly unwell and called Mr C for assistance. He took her to the Royal Alexandra Hospital where her condition continued to worsen. Ms A died of sepsis (infection in the blood) eleven days after giving birth to her son.

Mr C raised a number of complaints about the board's monitoring of Ms A's condition, the midwives' failure to note how ill Ms A was, and their failure to take Ms A back to hospital at the same time as her son. In each instance, we were satisfied that, based on the information available to staff at the time, there was no indication of a serious underlying condition. We acknowledged that the board had already highlighted some issues and had taken action to prevent these from happening again. We did not consider that these issues would have impacted on Ms A's care.

Summary

Mrs C complained about the care her son (Mr A) received from Cornhill Hospital in 2014. Mrs C was unhappy that Mr A's anti-psychotic medication was reduced and that his short-term detention under mental health legislation was revoked.

We took independent advice on this case from two mental health specialists. We found that it was reasonable for the medication to be reduced given that Mr A had not shown signs of psychosis or mood disturbances during his hospital admission. We also found that the decision to revoke the short-term detention was appropriate and in accordance with mental health legislation which sets out that at all times the least restrictive option is consistent with best practice.

Summary

Miss C had an ovarian cyst. A referral was made for it to be drained and possibly removed. The surgeon reviewed Miss C's notes the day before the operation was due to be carried out. They determined the procedure was inappropriate in the circumstances and that removal of both ovaries was recommended in guidelines produced by the Royal College of Obstetricians and Gynaecologists. Miss C was unaware of this change until she arrived at Aberdeen Royal Infirmary the following morning. After discussion, the operation went ahead. Miss C subsequently complained that consent was not properly obtained and that inappropriate treatment had been provided in light of her existing conditions, particularly fibromyalgia (a long-term condition that causes pain all over the body).

After taking independent advice from one of our advisers, who is a consultant gynaecologist, we upheld Miss C's complaint about consent. We found that the guidelines recommended removal of both ovaries in most cases but said that this should be determined by the wishes of the patient. The adviser considered that as it had been clear that Miss C had concerns, removal of just the affected ovary should have been discussed as a compromise, but this did not happen. We considered that Miss C should have been offered this information as part of the consent process. The adviser also highlighted concerns about the consent procedure, although it was noted that some changes had taken place following Miss C's complaint.

In relation to Miss C's other complaint, the adviser explained that there is a large volume of literature on the effects of hormones on fibromyalgia, but that most of the findings are contradictory. It was therefore considered that it would have been impossible to assess if the removal of both ovaries would affect Miss C's existing conditions and we did not uphold this complaint.

Recommendations

We recommended that the board:

• issue Miss C with an apology for the failure to advise her of the option of removing the affected ovary only; and
• review the process for obtaining consent, taking the adviser's comments into account.

Summary

Mrs C complained to us about the care and treatment her late father (Mr A) received at Aberdeen Royal Infirmary before his death from a urological cancer (relating to the urinary system and male reproductive system) that had spread through his body. Mrs C said that the urology care and treatment the board had provided to her father over a number of years had been inadequate. We took independent advice on this aspect of Mrs C's complaint from a number of medical advisers who are specialists in various relevant fields. We found that, although communication with Mr A and his family could have been better, there had been no major failings in relation to the urology service's care and treatment of Mr A. We did not uphold this complaint.

Mrs C also complained about the care and treatment the board had provided to her father over a number of years for his abdominal symptoms. We upheld this complaint, as we found that there had been a delay in carrying out a colonoscopy (examination of the bowel with a camera on a flexible tube) or alternative investigations. Although this led to a four-month delay in diagnosing Mr A's rectal tumour, there was no impact on the overall outcome, as the tumour was benign (non-cancerous). Mr A's urological cancer had already spread to other parts of his body by that time.

Mrs C also complained that the board had provided inadequate care and treatment to her father in the last few weeks of his life. Although we found that the care Mr A had received in relation to his visual problems had not been adequate, we found that the end of life care provided to him had been reasonable overall. We did not uphold this aspect of the complaint.

Finally, Mrs C complained about the board's handling of her complaint. We found that the board's former medical director should have ensured that Mrs C's correspondence to him was dealt with as a complaint rather than trying to deal with the matter personally. We also found that comments the former medical director had made to Mrs C in an email had been inappropriate, and that it had also been inappropriate to send Mrs C a gift voucher. In view of this, we upheld this aspect of Mrs C's complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for the failings we identified;
• take steps to make the surgical staff responsible for the delay in the colonoscopy or alternative investigations being carried out aware of our decision on this matter and consider if the matter should be discussed at their annual appraisal;
• make the staff in the gastroenterology team aware of our comments on communication with Mrs C and Mr A;
• provide us with evidence that steps have been taken to improve the care delivered to patients with visual impairments since Mr A was in hospital; and
• provide evidence to us that the recommendations made in relation to their investigation into the former medical director's actions have been implemented.

Summary

Mrs C complained that her brother (Mr A), who has mental health problems, was able to access alcohol and/or illicit drugs while he was a patient in the Forth Valley Royal Hospital. Mr A did not give his consent for Mrs C to pursue her complaint on his behalf with the board or us, so we were unable to investigate her specific concerns. However, we did investigate the matter in general terms to ensure that the board had sufficiently robust policies and procedures in place to address the types of concerns Mrs C was raising.

We took independent advice from a mental health nursing adviser. We reviewed the relevant national legislation, the Mental Health (Care and Treatment)(Scotland) Act 2003 and the Mental Health (Safety and Security)(Scotland) Regulations 2005. The adviser was satisfied that the board's policies and procedures complied with the legislation and were practical, clear and reasonable. In these specific circumstances, we were unable to determine if the policies and procedures had been followed in Mr A's case. However, we were satisfied that the policies and procedures were sufficiently robust to ensure patient safety if used appropriately.