Health

Summary

C complained that nursing staff failed to provide them with adequate personal care following an enema (an injection of fluid into the lower bowel by way of the rectum to expel its contents, to introduce drugs or to permit X-ray imaging) at University Hospital Monklands. C also complained about the provision of toilet facilities on a ward. They said that their experience had caused significant trauma. We took independent advice from a nursing adviser. We found that there was insufficient evidence to suggest that that the board provided C with inadequate personal care. We did not uphold this complaint.

C also complained that the board had failed to communicate effectively with them after they had a laparoscopy (an examination of the abdominal organs using surgical methods to determine the reason of pain or other complications of the pelvic region or abdomen) at a private hospital under a waiting list initiative. They said that this had caused delay to their treatment. We found that there had been a delay in communicating the results of the laparoscopy to C and this caused delay to C's treatment. The board were wrong to consider that C's GP should have discussed the results of the laparoscopy with them. The board requested the laparoscopy and it was their responsibility to discuss this with C. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to adequately communicate the results and/or findings of the laparoscopy with C. The apology should meet the standards set out in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

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

• Staff should be aware of their responsibility to directly discuss the outcomes and/or findings of tests or procedures they have requested with their patients.
• They will ensure that mistakes are rectified.

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 had a wisdom tooth extracted by the board. Subsequently C experienced an altered sensation in their tongue and was advised that this was likely the result of nerve damage, which was a possible side effect of the extraction of a wisdom tooth. C complained that they were not advised of this possible side effect prior to the extraction taking place. A handwritten note on the consent form C signed included mention of altered sensation but C disputed that this had been present when they signed the form.

We took independent advice from a dentist. While evidence gathered as part of our investigation could not definitively determine which of these positions was most accurate, we considered that based on the available evidence, the board did not make C reasonably aware of why the extraction was considered necessary, what the risks and benefits of extraction, alternative treatments or no action were, what the percentage likelihood of nerve damage was or what 'altered sensation' meant. Therefore, we found that the board did not reasonably advise C that nerve damage was a possible side effect of the extraction of a wisdom tooth as required and upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably advise that nerve damage was a possible side effect of the extraction of a wisdom tooth. The apology should make clear mention of each of the points the board did not make C reasonably aware of. 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 are provided with clear information of the nature of the proposed dental treatment, the purpose of treatment, the risks and benefits to treatment in comparison to no treatment and any alternative treatment options, and valid consent is obtained and recorded in line with the General Dental Council's Standards For The Dental Team Principles.

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 following their hip replacement surgery. Immediately following the surgery, C began experiencing severe and continual pain. The cause of C's pain was eventually confirmed to be loose cement from the surgery causing irritation. C complained that, although the surgeon who had carried out their hip replacement was aware of the loose cement, this was not conveyed to C. Instead, C had consultations with a total of five consultants before the source of their pain was identified two and a half years after their surgery and remedial treatment successfully provided.

C raised a number of concerns regarding the attitude shown towards their symptoms by the board's consultants and the delays to diagnosing and resolving their pain.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that C's surgery was carried out reasonably and that there was no immediate indication of the complications that they would subsequently experience. We noted that it is not uncommon for patients to experience pain for up to 12 months following a hip replacement. We were generally satisfied that the board's staff took C's pain seriously and carried out reasonable investigations to establish its cause. We also noted that leaked cement is not uncommon and would not initially be viewed as a likely source of a patient's pain.

We considered that the complications C experienced were extremely rare and required specialist intervention. We found that it was not until an x-ray taken a year after surgery that it became apparent that a large amount of cement had leaked from the surgical site and a later MRI scan identified that C had a degree of psoas tendinopathy (an inflammation of the tendon or area surrounding the tendon).

Whilst we were satisfied that the clinical team followed a reasonable path to establishing and treating the cause of C's pain, we were critical of the time taken to conduct a CT scan following the MRI scan and of the time taken to provide surgery to resolve the issue. Therefore, we upheld C's complaint on that basis.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable delays during the diagnosis of and in arranging the treatment of C's postoperative complications. 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:

• The board should arrange for this case to be presented at a local clinical governance meeting (with radiologists present) where the case and imaging should be reviewed.

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 to their adult child (A) during two admissions to Aberdeen Royal Infirmary where they had been admitted for investigation and treatment of persistent vomiting and weight loss. We took independent advice from a nurse and asked for their comments on A's care and treatment during both admissions.

During the first admission, C complained about A being given incorrect medication, comfort and observation charts being completed inaccurately, and of the poor level of cleanliness in the ward's bathroom. We found that there were failings in these areas, which the board had acknowledged in their own complaint investigation and had identified actions for improvement and learning. Therefore, we upheld this aspect of C's complaint and asked the board to provide evidence of the actions that they had said they planned to take.

During the second admission, C complained that A was given the wrong nasogastric feed and failed to take proper action when A self-harmed; was provided with the wrong type of feeding tube; staff failed to communicate properly with C or A during the admission; and A was not given medication on discharge.

We found that the care of A's enteral feed (feeding tube leading into the stomach) to be reasonable, however we found that the planning and documentation of A's care after they had self-harmed was unreasonable. We also found that A had been given the wrong length of feeding tube and that the procedure went ahead despite this being known. Therefore, we upheld these aspects of C's complaint.

We found that communication with A had been reasonable and we did not uphold this aspect of C's complaint. In relation to communication with C, we found this to be mostly reasonable, however there had been a serious oversight in communicating with C when A had self-harmed. Therefore, on balance, we upheld this aspect of C's complaint.

In relation to A's discharge, we found this to be reasonable and we did not uphold this aspect of C' complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for the failings we have 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:

• The board should ensure staff are aware of how to report and respond to incidents of self-harm when they occur within acute care settings.
• The board should ensure the correct type of feeding tube is used according to the planned procedure.

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 treatment that they received from the Golden Jubilee National Hospital. C had surgery to address a non-union of the bones in their mid-foot. Just under a year after their surgery, C submitted a complaint to the hospital, noting that the surgery had failed and that they required a second operation due to the non-union of the affected joint in their foot. C said that they accepted that non-union was a known risk of this surgery. However, having reflected on their experience and having discussed their case with another orthopaedic specialist (a specialist in the treatment of diseases and injuries of the musculoskeletal system), C believed that the care provided by their consultant was inadequate and may have been a contributing factor in the failure of their surgery.

We took independent advice from a consultant orthopaedic surgeon. We found that, whilst there was some confusing communication as to the type of surgery that C would undergo, the consultant's choice of procedure was reasonable and the reasoning behind it was valid. C's case was not straightforward due to a previous failed fusion surgery. We were satisfied that the clinical treatment provided was reasonable and that the actions of the board's staff did not contribute to the failure of the joint to fuse.

However, we were critical of the board's decision to discharge C before it was clear that their surgery had been successful. Whilst the outcome would not have been any different for C surgically, ongoing monitoring and review would have allowed for potential issues to have been identified sooner and for the clinical team to have had discussions with C regarding the status of their fusion and their ongoing treatment options. Overall, whilst we found that the clinical care and treatment was reasonable, we were critical of C's early discharge and the quality of the communication from the clinical team. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted in this decision. 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:

• The Golden Jubilee National Hospital should share this decision with their orthopaedic staff with a view to identifying ways that they can improve the care and treatment provided to future 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 provided to their parent (A). A had Alzheimer's disease (the most common cause of dementia) and C had a full power of attorney (POA) in place that was active at the time. This enabled C to make decisions about A's welfare.

A was admitted to Forth Valley Royal Hospital via the acute assessment unit, and was later transferred to a ward. C said that when admitted to hospital A was continent, could walk with a stick, slept through the night, and was eating and drinking. C said that the board made inappropriate changes to A's medication during their admission, and that, when later discharged, A had lost weight, was not eating and drinking, was very frail and could not stand up, and was doubly incontinent. C also had concerns about the way A was treated and spoken to by nursing staff, and that they were discharged with a very large pressure ulcer.

The board apologised for the way in which A was spoken to and treated by nursing staff and that the staff involved have received training and would be monitored going forward. The board also said communication with family members was not documented as it should have been.

The board said it would be expected for A's weight to reduce as they lost excess fluid. They explained that there was a change in A's appetite during their admission, however acknowledged that a referral to a dietician should have been made in light of this change in A's appetite.

The board said that A's mobility was at one point assessed as unsafe, but later it was recorded that A could mobilise with a walking frame. A's continence was recorded as variable during their stay and that A would often get up and mobilise to the bathroom.

In relation to A's pressure ulcer, the board said that A had pressure damage to their sacrum (lower back) on admission to the ward and that it was documented regularly over A's admission.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a nurse. We found that the medical care and treatment provided by the board, including changes in medication, was reasonable. However, the overall nursing care, and particularly the record-keeping, was unreasonable. We also found that the board did not communicate reasonably with C about A's care, discharge, or their ongoing needs

Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures which the board have not already offered an apology for in previous correspondence. 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:

• Communication with those with POA should be of a reasonable standard. When a patient has been assessed as not having capacity, POA holders should be included in discussions and arrangements for a patient's care and discharge. The board should follow their process for assessing capacity including obtaining a copy of the POA paper work and keeping it within the clinical record of the patient.
• Patients with increased confusion should be appropriately assessed in line with Healthcare Improvement Scotland guidance and relevant records (such as the TIME bundle) completed as appropriate.
• Pressure ulcers should be assessed and appropriately graded, in line with the board's guidance for pressure care management.
• Records should be accurate and up-to-date. All charts should be completed appropriately and consistently. Patients who are experiencing issues with continence should receive appropriate support. Fluid balance charts and care and comfort checklists should be utilised to help support effective management of incontinence.
• The board should communicate with family members regularly and effectively, and the detail of conversations should be recorded. Families, where appropriate, should be involved in the discharge planning process, especially for people with a diagnosis of dementia.

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 their child (A) received from a dentist at the dental surgery. C raised a number of concerns, including that the dentist failed to detect decay in A's tooth and provide appropriate treatment for this, and failed to carry out a radiograph (a type of dental x-ray) on A's tooth sooner.

We took independent advice from a dentist. We found that the dentist failed to record the presence of a mark on A's tooth during their third appointment, assess if there had been any deterioration of that mark, carry out further investigations and carry out radiographs at an earlier stage. We also found that the dentist's notes had extremely limited detail added and were below the expected standard. Given the failings in the detection and treatment of the decay in A's tooth and in carrying out a radiograph sooner, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for failing to record the presence of the mark on A's tooth, assess if there had been any deterioration of that mark, carry out further investigations and carry out radiographs at an earlier stage. 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:

• In cases of this type, dentists should assess if there have been any deterioration of marks on patients' teeth and carry out further investigations, as appropriate.

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 from the board during an in-patient stay at Forth Valley Royal Hospital. C was admitted to the hospital while in the early stages of labour. C gave birth a few days later and was discharged to their home the following day. After discharge, C's health began to deteriorate and were later admitted to a different hospital, where they received a blood transfusion and treatment for an infection.

C complained that the board had failed to inform them that they had a yeast infection and failed to provide them with any treatment for this. C also complained that a clinician knowingly recorded an inaccurate pulse rate on their records and that the board failed to appropriately treat their post-natal high blood pressure and/or blood loss.

We took independent advice from an obstetrician (a doctor who specialises in pregnancy and childbirth). We found that the board had failed to inform C that they had a yeast infection. Therefore, we upheld this aspect of their complaint.

We found insufficient evidence to establish that an inaccurate pulse rate had been recorded on C's records. We also found that C's blood pressure and/or blood loss were within normal limits when they were discharged from hospital. Therefore, we did not uphold these aspects of C's complaints.

However, we did find that clinicians failed to reasonably respond to C's high pulse rates at one point during their admission. While this issue was not raised by C in their complaint, we considered that it was reasonable to make recommendations to the board in relation to this matter.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to adequately monitor and respond to their condition. 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:

• Clinicians should closely monitor Modified Early Warning Scores (MEWS) and appropriate action should be taken in light of them.
• When a candida (yeast) infection is identified, patients on the ward should be informed.

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 board regarding the care and treatment provided to their late parent (A). Following a diagnosis of bladder cancer, the board identified that A would require heart surgery before they would be fit enough for bladder surgery. They referred A to another health board to provide that surgery, but this took a number of months to arrange and carry out. C told us that, by the time the heart surgery was completed, A's cancer had progressed to a point where treatment was no longer possible.

We took independent advice from an oncology consultant (a doctor who specialises in the diagnosis and treatment of cancer). We found that the board failed to identify radiotherapy as a possible alternative treatment, despite this advice being given by their oncology team. In addition, we found that the board had mishandled the referral to the other health board for heart surgery, failing to ensure that the other board were made aware of the urgency required. Then, when there were inevitable delays in surgery as a result, the board failed to identify that the window for treatment was closing.

For these reasons, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with a reasonable standard of cancer 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:

• A full range of treatment options should be considered when deciding on a treatment plan, and reconsidered if the viability of the original plan changes.
• All referrals made to other boards for treatment should include full details of any time sensitivity around treatment. Where it is unclear if treatment can be provided quickly enough, direct communication should occur between the relevant teams to explore this and alternative treatment options.

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 failed to provide them with reasonable treatment. C was hospitalised with a right sided homonymous hemianopia (a visual field defect involving the two right, or the two left, halves of the visual fields of both eyes). C believed that a previously diagnosed arachnoid cyst (a non-cancerous fluid-filled sac that grows on the brain or spinal cord) could be the underlying cause of their clinical symptoms. C underwent CT and MRI scanning.

The board concluded that C's arachnoid cyst was stable and unchanged from a previous MRI, and was unlikely to be the cause of their vision loss. Following a deterioration in their symptoms, C sought private neurosurgical opinion (specialist in surgery on the nervous system, especially the brain and spinal cord) and underwent a craniotomy (procedure to open skull to gain access to the brain) to drain the cyst resulting in partial and ongoing recovery of their vision.

C complained to the board that they should have been referred for neurosurgical review and received treatment through the NHS pathway sooner. They said that clinicians leading their care had repeatedly dismissed their concerns that the cyst could be the underlying cause of their symptoms and had excluded several sources of significant information from the clinical decision-making process, including a discrepancy in the scan measurements which had in fact shown the cyst had increased in size.

We took independent advice from a neurosurgical adviser. We found that, despite a marginal increase in the cyst identified through retrospective radiology analysis, C's progressively worsening symptoms could not have been explained purely on the basis of imaging, and there was no evidence to support an argument that an earlier opinion from a neurosurgeon should have been requested. Our investigations found that although multi-disciplinary opinion may have been helpful in this particular case given C's continuing and unexplained neurological symptoms, the board had carried out appropriate investigations and specialist opinions had been sought on multiple occasions to inform decision-making regarding C's care pathway. Therefore, we did not uphold the complaint.

In investigating C's complaint, the board identified that there had been a break in their communications with C. We considered the action taken by the board to address this had been reasonable; however reminded them that in line with the published Model Complaints Handling Procedure, steps should be taken to ensure complainants are kept up to date and given revised timescales for response.