Health

Summary

C complained that the medical practice failed to provide reasonable care and treatment to their spouse (A) after they presented with a lump in their right breast.

We took independent advice from a GP. We found that the time taken to refer A to hospital when they first consulted the medical practice with the lump in their right breast was unreasonable. It was also unreasonable that the referral was not marked as urgent.

The medical practice had carried out a detailed review of A’s care and had accepted that there was a complete systems failure in the care and treatment provided to A. They had made a number of changes which we welcomed and considered were appropriate. Nevertheless, we found that they had not fully acknowledged their specific role and responsibility in relation to the failings which had occurred given their responsibilities for the supervision, training and actions of their employed staff.

We also identified additional issues not addressed by the medical practice in their consideration and response to the complaint. In particular, that the medical practice should have a system in place to ensure any outstanding referrals were identified when a colleague is unexpectedly absent due to sickness or ill-health and that it was unreasonable that A was not contacted by the medical practice after the cancer diagnosis given the significance of the diagnosis and their delay in sending the referral and marking it as urgent. We also found that the medical practice did not appear to have considered their duty of candour responsibilities in this case. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients should receive appropriate assessment and referral in line with relevant guidelines. Patient referrals should be reviewed and actioned when the responsible member of staff is absent unexpectedly. Where appropriate, patients should be contacted after receiving a significant diagnosis. This should include when the practice become aware that harm has occurred as a result of an unintended incident in healthcare to take into account duty of candour responsibilities, individual roles and their role responsibilities in making sure this happens.

In relation to complaints handling, we recommended:

• The practice should ensure that, where failings have been identified during a complaint investigation, the investigation and response fully acknowledges and take responsibility for the failings and ensures there is appropriate learning across the practice.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the board took too long to offer them steroid/local anaesthetic injections for vulvodynia (chronic pain or discomfort in the vulva). C felt this was dismissive and unsatisfactory. The board said that C did not receive the treatment initially as it was not clinically appropriate at that time. They said in order for the treatment to be effective, there should be a locally tender area to inject which C did not have. The board added that it was important to note that the treatment is unlicensed and so is only to be considered for use when definitely clinically indicated.

We sought independent clinical advice from a consultant. We found that it is right for the board to have a cautious approach to the use of unlicensed treatment. We noted that the treatment C received for many years was reasonable. However, it was later indicated that C had developed a localised area of pain and it would have been reasonable to discuss the treatment with C at that point.

We considered that whilst the care and treatment provided to C was generally reasonable, the board should have discussed the treatment option of steroid/local anaesthetic injections earlier than they did. For this reason, on balance, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not discussing the pros and cons of steroid/local anaesthetic injections as a treatment option or offering C the chance to decide whether or not they wanted to try this treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients attending vulval pain clinics should be fully informed about their condition as well as the pros and cons of available treatments. Staff caring for patients attending vulval pain clinics should be aware of the full range of treatment options so that they are able to provide holistic care and advice to patients.

In relation to complaints handling, we recommended:

• Complaints should be responded to in line with the Model Complaints Handling Procedure (MCHP) and issued within the expected timescale of 20 working days. If the board are unable to meet the 20-working day deadline, updates and a new deadline should be issued to C in line with the MCHP.
• Letters of complaint received by the board should be logged and forwarded as appropriate to the complaints and feedback team.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment they received from the board having required hip surgery following a fall. Specifically, C was concerned about the type of hip surgery they received, their post-operative care, the arrangements made for their discharge home, and the way in which the board had responded to their complaint. In responding to C, the board did not uphold the failings they had identified, and they provided a rationale for the type of surgery C received, and for the care and treatment given.

We took independent advice from an orthopaedic surgeon (specialist in the treatment of diseases and injuries of the musculoskeletal system). We considered the procedure chosen for C to be evidence based and appropriate to their particular circumstances. We also found the post-operative care and discharge planning for C to be reasonable. Finally, we considered the board’s complaint response to have appropriately responded to the matters they had complained about. Therefore, we did not uphold C’s complaints.

Summary

C complained on behalf of their parent (A) for whom they hold power of attorney. C complained that the practice had incorrectly diagnosed and treated A with chronic back pain. C stated that A was later admitted to hospital with a fractured back and pneumonia.

The practice advised that there was nothing to clinically suggest a fracture at the time and it would not have altered treatment. They noted that A did not have pneumonia as per hospital discharge.

We took independent advice from a GP. We found that a thorough physical examination was undertaken which did not raise concerns of a fracture. We also found that appropriate pain relief is the only immediate treatment for vertebral fractures. There were no symptoms of pneumonia when the patient was seen by the GP and no suggestion of pneumonia in the medical records. We did find one mention of pneumonia in a letter between two third party medical professionals, who were not involved in A’s hospital care. Therefore, we did not accept this as evidence of a pneumonia diagnosis. In light of this, we found that the overall care and treatment provided to C was reasonable and did not uphold C’s complaint.

Summary

C complained about the care and treatment their adult child (A) received from the practice. A had undergone surgery to remove infected fluid on the right lung. Gabapentin (an anticonvulsant medication primarily used to treat partial seizures and neuropathic pain) was prescribed to manage nerve pain at the incision site. The practice later stopped prescribing gabapentin and A’s mental health deteriorated significantly.

C complained about the abrupt withdrawal of gabapentin. They highlighted that gabapentin had been prescribed to manage ongoing nerve pain following surgery and noted the risks of sudden withdrawal. The practice stated that prior to the discontinuation of gabapentin there had been an increase in early requests for renewal of medication, which caused concern. A had not attended appointments with the GP or with cardiology (specialists in diseases and abnormalities of the heart). The GP felt that they could not justify further prescription of controlled drugs without seeing the patient.

We took independent advice from a GP. We found that there was no record of any significant harm from gabapentin or evidence of overuse, or had there been any discussion around reducing or stopping gabapentin. We noted that gabapentin is known to cause problems during the withdrawal period and it should therefore be withdrawn slowly. We also found that no withdrawal support was given. In light of this, we considered that the practice had failed to appropriately manage A’s prescription for gabapentin and upheld C’s complaint.

We also found failings in the practice’s handling of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for abruptly stopping gabapentin. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A for the complaint handling issues. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Complaint acknowledgements should include all the information required by the Model Complaints Handling Procedure. Points of complaint should be agreed with the complainant at the outset. Points of complaint should be addressed in the response. Care should be taken with the tone of the response.
• GPs should be familiar with the guidelines for withdrawal of medicines associated with dependence.
• The practice should have a policy around how they contact patients especially when their phones are unobtainable. Alternative modes of communication like home visit, letter or taking help from a household contact to confirm phone number could help clinicians provide safe care to patients.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment that they received in relation to their mental health from the board over the course of just over a year. C was also concerned about the treatment that they received from a psychiatric consultant including consideration of referring C to a different health board and dealing with complexities in the case, such as C’s parent being employed by the board. We took advice from an independent psychiatric nursing adviser. We found that the overall standard of treatment provided to C was reasonable and did not uphold this complaint.

C was also concerned that the board unreasonably delayed the organisation of community mental health care to them due to concerns over safety and risk. Although C was ultimately referred to the specific community mental health team outwith the area that they had requested from early in the process, we found that the board’s regard for the potential risks of such an arrangement were reasonable and that, overall, there was no unreasonable delay due to the board’s action and that the standard of care provided was reasonable. We did not uphold this complaint.

C was further concerned that the psychiatric consultant did not reasonably record their assessment and reasoning of decisions to hospitalise C, to prescribe medicine to C or to refer C to a psychologist. We found that record keeping over the relevant period had been reasonable and that, taking all of the available evidence, the psychiatric consultant had reasonably recorded their assessments and reasoning regarding C’s treatment. We did not uphold this complaint.

C was concerned about delays in the board responding to complaints about their care and treatment, the board’s inability to explain the reasons for those delays and the board’s failure to provide a copy of a response to an elected representative as C had requested. While the board had accepted some of these failures during their consideration of the complaints submitted or while responding to our enquiries we also concluded that, contrary to the board’s views, the reason for these delays were confusion within the board and a lack of clear responsibility for responding to the complaints. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Re-iterate their apologies to C for the unreasonable delays in responding to the complaints and their unreasonable failure to provide a copy of their response to their MSP as they had requested. Apologise to C that they did not provide reasonable explanations for the delays in responding to the complaints. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Establish a clear hierarchy of responsibility for complaint responses and a system of escalation to senior management for circumstances where complaints have not been responded to within three times the length of a timescale in the Complaints Handling Procedure, or Complaints and Feedback Team follow up messages do not result in action to progress matters.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided by the board to their child (A) during a consultation with an orthoptist (specialist in the diagnosis and treatment of eye movement disorders) and optometrist (healthcare professional who provides primary vision care) in relation to the management of A’s strabismus (a squint) and wide-angled esotropia (inward turning of the eye). C made several complaints, including the board's failure to assess the size of the squint, failure to adequately dilate A’s irides using cycloplegic drops (drugs used to paralyse muscles in the eye), issuing a prescription for glasses based on an inaccurate refraction test result, displaying poor clinical knowledge about A’s condition and poor record-keeping. C also complained about how their complaint had been handled by the board, particularly in relation to a meeting that had taken place to discuss the complaint.

In response, the board stated that, while A’s refraction test indicated a greater amount of myopia (short-sightedness) than previous tests, differences could occur for a variety of reasons, such as the amount of dilation of the irides. In patients with dark irides, such as A, dilation could be difficult but this had been recognised by the clinicians and drops to dilate were appropriately re-instilled, with the prescription issued in accordance with the test results. The board accepted, however, that there had been communication issues between the orthoptist and optometrist but measures had been put in place to improve this. The board also agreed to amend A’s notes to reflect more accurately what had been discussed at the consultation and arrange a further review of A much sooner than had been agreed.

We took independent advice from a consultant in paediatric ophthalmology. We found that A’s refraction test results were inaccurate and should have caused the optometrist to question whether A’s irides had been adequately dilated rather than issuing an incorrect prescription. We also found that the records showed that the drops instilled by the clinicians had been administered at inappropriate intervals, which had likely resulted in A’s irides being inadequately dilated. We were critical of the board’s handling of the complaint, particularly in relation to the board taking advice from an optometrist who had insufficient clinical experience of the issues under consideration. Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A’s care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Where the outcome of a refraction test indicates that a significant increase to a prescription is required, clinicians should (i) question whether the patient’s irides have been sufficiently dilated, particularly in patients with darkly pigmented irides; and (ii) consider whether it is necessary to repeat the refraction at a follow-up appointment rather than proceed to issue the increased prescription.
• Where different types of eye drops require to be administered in order to achieve dilation of irides before carrying out a refraction test, clinicians should administer each set of drops at intervals of at least five minutes.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C and their pregnant partner (A) attended a local hospital as A was experiencing abdominal discomfort. A was examined and recommended to attend the main regional hospital, advising C to drive them there. The journey time was approximately 3 hours and on arrival A was examined and advised that labour may be starting. A was later told that labour was unlikely to be starting but remained in hospital overnight and discharged the following day.

The following week, A suffered vaginal leakage and attended the local hospital where they were examined by a clinician and advised that they suspected A’s waters had broken. A was advised to go to the main regional hospital and they were told that an ambulance was not needed. C therefore drove A to the main regional hospital.

An examination at the main regional hospital revealed that A’s waters had broken and in the early hours of the following day they went into labour. Later that afternoon clinicians gave A and C a number of options: continue with natural labour, attempt a process of augmentation (helping along a labour that's not progressing as it should), or an immediate caesarean delivery (an operation to deliver a baby that involves cutting the front of the abdomen and womb). A and C both agreed to a caesarean. The procedure was carried out and the baby (B) was delivered. However, clinicians had to resuscitate B.

A scan of B’s brain three days after birth revealed a likely injury which was later confirmed as periventricular leukomalacia (PVL, a softening of white brain tissue near the ventricles which often causes problems later with muscle control and thinking or learning problems). Following repeated scans over several weeks as the cysts continued to form, this was eventually categorised as grade three level of severity.

C raised concerns with the board regarding the care and treatment that A and B had received. C met various clinicians but remained dissatisfied. The board offered to have the events subjected to an external review but terms could not be agreed and the review was not carried out.

We took independent advice from a neonatal consultant. We found that, during both admissions, the board failed to provide reasonable care to A and their unborn child and that the board failed to fulfil their obligations under duty of candour. We upheld the complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to provide optimal care, for failing to carry out adequate assessment, for failing to complete suitable documentation and for failing to make safe transport arrangements. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C and A for failing to provide reasonable care by omitting to timeously administer prophylactic antibiotics to A on arrival at the regional hospital and apologise for the board failing to fulfil their duty of candour obligations when the antibiotic incident was identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The board should offer C a final opportunity to address their outstanding questions in relation to the care of A and B in a format agreeable to both parties.

What we said should change to put things right in future:

• Establish record keeping systems that prompt midwives to detail a full assessment and ensure there is cross checking with the consultant unit at the regional hospital.
• Establish a protocol for managing premature rupture of membranes in remote locations and commence treatment where appropriate, prior to transfer.
• Establish standard documentation and standard operating procedures for risk assessing pregnant women in remote locations, to determine the most appropriate mode of transfer to the obstetric units.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about treatment they received in relation to an alleged failure to promptly identify and treat developing symptoms of cauda equina syndrome (CES, compression of the nerve roots in the lower back affecting various neurological functions). C was initially admitted to hospital within another health board area before being discharged the following day on the basis that there was no evidence of CES at that time. However, C re-presented to the emergency department at the same hospital four days later with new symptoms thought to be CES. On the basis of advice provided by NHS Greater Glasgow and Clyde’s neurosurgical department at the Queen Elizabeth University Hospital (QEUH) to clinicians at the health board, C was fasted and underwent an MRI scan the following morning, which showed a large disc protrusion compressing the cauda equina nerve roots. C was thereafter taken by emergency ambulance to the QEUH where they underwent surgery the same day.

In order to investigate the neurosurgical advice provided by NHS Greater Glasgow and Clyde to the other health board, we took independent advice from a consultant neurosurgeon. We found that the advice provided had been reasonable given that it was well accepted practice that surgery to decompress the cauda equina nerve roots should be performed within 24-48 hours of a patient presenting to hospital, which had occurred in this case. Therefore, we did not uphold C's complaint.