Health

Summary

Ms C complained about the post-operative medical care she received after Tension Free Vaginal Tape Obturator (TVTO) surgery for urinary incontinence at the New Victoria Infirmary in May 2011. After the operation, Ms C suffered constant pain until further tests revealed a year and a half later that she had suffered bladder erosion (where the tape has eroded into the bladder). Ms C was concerned that a cystoscopy (where a camera is used to check for abnormalities) was not used when the tape was implanted, and was unhappy about the time taken to identify this injury. Ms C had a further operation at the Southern General Hospital in November 2012 to have the tape removed. She complained about the nursing treatment for her wound, which became infected a week later, and that the board's response to her complaint did not address her concerns that her wound was not checked during the first week after surgery.

There are no national guidelines recommending that a cystoscopy be performed on all patients undergoing TVTO surgery, and the manufacturer's product information says that it is at the discretion of the surgeon whether to perform a cystoscopy. After taking independent advice from one of our medical advisers, we did not consider it unreasonable that a cystoscopy was not performed. TVTO had been introduced to reduce the likelihood of bladder injury, and it was not the board's policy in 2011 to perform a cystoscopy on all patients undergoing TVTO. After numerous cases of injury with the TVTO procedure were reported over the years, however, this eventually led to the board's change of policy in 2012. Nevertheless, we were critical that when Ms C complained five months later of pain and recurrent bladder infections, a cystoscopy was not arranged as supported by guidance issued by the National Institute of Clinical Excellence.

Although we found that Ms C's wound was checked and redressed twice in the week after her surgery at the Southern General Hospital, there was evidence to suggest that there were three consecutive days when it was not checked, before she told nursing staff that it was painful and leaking. Healthcare Improvement Scotland makes clear that wound charts should be started for all patients with a wound, and we noted that in Ms C's case this chart was not started until after her wound became infected. We concluded that the nursing care fell below the reasonable standard that would be expected in this surgical ward. In addition, the board did not respond to Ms C's complaint about her wound not being checked during the week after surgery and instead concentrated on the redressing that took place after the infection was identified. We upheld Ms C's complaints.

Recommendations

We recommended that the board:

• ensure that complaint responses fully address the concerns raised, in line with the Scottish Government's complaints handling guidance;
• ensure that appropriate staff take into account the relevant guidelines on performing a cystoscopy in patients with pain and recurrent bladder infections following pelvic surgery;
• draw to the attention of relevant nursing staff on the surgical ward at the Southern General Hospital the importance of having in place wound charts in line with Healthcare Improvement Scotland guidance and ensure daily dressing and/or wound inspections are conducted; and
• apologise to Ms C for the failings identified.

Summary

Mr C complained about his care and treatment after a road traffic accident. He complained that the physiotherapy service had not diagnosed his injuries correctly and were overly focused on possible legal action that he was pursuing. Mr C believed that this meant they did not believe his description of his injuries, or the amount of pain he was in. He also felt this influenced the pain clinic he was referred to, where he said staff were also dismissive of symptoms that he maintained were caused by spinal injury. Mr C later paid for a private scan of his spine, which revealed some damage to a spinal disc, which he believed proved the pain he was experiencing had a physical source.

Mr C also said that the board did not investigate his complaint properly. His first letter of complaint was lost, even though it was signed for on delivery. He said that they did not then investigate his complaints about the physiotherapy treatment, concentrating instead on his treatment at the pain clinic.

We took independent advice on Mr C's complaint from two of our medical advisers. The advice we received was that Mr C had received a comprehensive assessment, and that treatment for whiplash associated disorder had initially improved his symptoms. He returned to the physiotherapy service when his symptoms became worse. As he did not then respond to treatment, he was referred appropriately to the pain management clinic. We found no evidence that Mr C's symptoms were treated differently or inappropriately due to a focus on legal action. The private scan showed changes that were normal for a man of Mr C's age and they were not in keeping with the symptoms Mr C described. The treatment Mr C received was appropriate, and in keeping with guidelines and best practice on treating whiplash injuries. Both advisers said that the evidence showed that Mr C's care and treatment was reasonable.

Our investigation found that the board acknowledged that Mr C's initial complaint letter was misplaced, but also that it did not contain enough information to support an investigation. When they became aware that Mr C wanted to complain, they repeatedly tried to establish what he was complaining about, but Mr C did not provide information to the board until we told him he should do so. The information he then provided was limited, and the board were unable to investigate the complaint about the physiotherapy service. They did investigate his complaint about the pain clinic. We did not uphold Mr C's complaints.

Summary

Mr C complained on behalf of his uncle (Mr A) for whom he holds power of attorney (a legal document appointing someone to act or make decisions for another person, with their permission) as Mr A suffers from dementia. Mr A also suffers from a condition that affects his spine and neck and can cause loss of function in the upper limbs. Because of where he lives, Mr A had to travel, accompanied by Mr C, to another health board area for orthopaedic assessment (assessment of conditions of the musculoskeletal system) and treatment. Mr C complained that an operation was cancelled without any alternative treatment being offered or discussed; that a six-month follow-up appointment did not take place until twelve months after Mr A's cancelled operation; that some expenses incurred were not refunded; and the board failed to respond to complaints within a reasonable timescale.

Mr A was assessed by a locum (temporary) consultant orthopaedic surgeon in June 2012 and was told that he needed life-saving surgery for his condition. His operation was scheduled for August 2012, by which time a permanent consultant orthopaedic surgeon had been appointed. When Mr A went to hospital for the operation he was reviewed by that surgeon, who took a different view from the locum and said that more conservative, non-surgical management of Mr A's condition was appropriate. Mr A was told this without his nephew being present, despite Mr C's specific request that no clinical discussions take place without him there. Mr A was discharged the same day and sent home with a promise of a follow-up appointment in six months' time.

Our investigation included taking independent advice from an orthopaedic surgical adviser, who was of the view that the decision not to operate and to review Mr A again in six months was reasonable. The adviser said that the threshold for surgical intervention can vary between consultants, and when a patient is managed by more than one consultant this kind of experience is always a possibility. The adviser was of the view that neither the locum's nor the surgeon's approach was wrong, and we did not uphold the complaint about the cancellation.

We did, however, uphold Mr C's other complaints. When no follow-up appointment date was given, Mr C chased this up but it was not until after he contacted us in April 2013 that an appointment was arranged. This eventually took place in August 2013 - almost a year after the operation was cancelled. Although our adviser was able to reassure Mr C, Mr A and us that Mr A's condition had not progressed in that time, and so the delay had not had a detrimental effect on his condition, we found this delay unacceptable.

On the matter of the expenses, the board acknowledged that as the operation was cancelled at such a late stage Mr C and Mr A had incurred unnecessary expenses, and told us that they were prepared, as a gesture of goodwill, to refund these. However, this did not happen until we chased this up some eight months later.

On the final complaint, our investigation found that the board had not responded to Mr C's complaints within the national or local guidance for complaints handling in place at the time. The board acknowledged this and apologised to Mr C about the handling of his complaints.

Recommendations

We recommended that the board:

• ensure, and provide the Ombudsman with confirmation, that all staff involved in this complaint are made aware of the importance of adhering to the national and local guidance on dealing with patients suffering from dementia;
• consider putting in place a monitoring system for orthopaedic appointments to prevent a recurrence of such a delay in future;
• urgently take action to ensure that Mr C and Mr A's applicable expenses are now refunded;
• ensure that all relevant staff are reminded of the need to keep complainants informed where there are unavoidable delays in the complaints process in accordance with the NHS Complaints Handling Guidance; and
• issue a written apology for the failings identified during this investigation.

Summary

Mrs C's mother (Mrs A) has a long history of various mental health illnesses, including dementia. In August 2008, Mrs A was detained in the Royal Cornhill Hospital under the Mental Health Act. She was there until January 2010, although planning for her discharge began in early 2009. Mrs A was initially discharged to a care home for respite care with a view to going to live with one of her daughters, but this turned out not to be possible, and she was transferred to another care home, where she currently resides.

Mrs C complained that the board failed to carry out appropriate assessments on Mrs A's eligibility for funding for NHS continuing health care (continuing care). She also complained that when she lodged an appeal about the decision not to grant funding, the board unreasonably failed to provide evidence to support their decision.

Our investigation, which included taking independent advice from a specialist adviser on continuing care, found that appropriate assessments of Mrs A's physical and psychiatric conditions were undertaken while she was in hospital and before her discharge, and we did not uphold this complaint. The adviser said that the assessments were used to inform the decision-making process, in line with national guidance on the application of decisions on funding for continuing care, and that there was no evidence that the decision-making process was not properly carried out.

We did, however, uphold the complaint about the information provided to Mrs C after the appeal decision, as we found that insufficient information was provided to Mrs C at both the initial decision-making stage, and the appeals stage. The adviser said that the lack of information provided to Mrs C meant that the process had not been clear and open as required by the national guidance.

Recommendations

We recommended that the board:

• review their NHS continuing health care decision-making process to ensure that it complies with the guidance, in particular in relation to the information provided to patients, carers, and relatives;
• provide Mrs C with all the relevant supporting information upon which the inital decision and the appeal decision were based; and
• issue a written apology for the failings identified during this investigation.

Summary

Mrs C complained about the care and treatment she received when she was admitted to Aberdeen Maternity Hospital to have her baby via an elective caesarean section (a planned operation to deliver a baby). The plan was for Mrs C to have spinal anaesthesia, but staff were unable to numb her spinal area. Mrs C complained that she was in extreme pain and that she asked staff to stop, but they did not listen to her and persisted in trying to provide spinal anaesthesia. Mrs C said that the pain stopped only when she was given a general anaesthetic.

We took independent advice on this complaint from one of our medical advisers. All the available information was taken into account, including Mrs C's clinical records and the complaints correspondence.

Our adviser said that spinal anaesthesia is a technique with a recognised failure rate. The clinical records indicated that the complications of the procedure were explained to Mrs C and alternatives were discussed with her. The adviser also said that the attempts to site the anaesthetic were made by appropriately experienced anaesthetists and the records showed that, given the particular depth of the space in Mrs C's body where they were trying to place the anaesthetic, any attempt to do so would be technically challenging. The records also indicated that because Mrs C wanted to avoid having a general anaesthetic, the anaesthetists persisted in trying to site a regional anaesthetic, and when Mrs C declined the option of awaiting labour, further attempts to site the regional anaesthetic were made. We found no evidence of any significant shortcomings in the management of Mrs C's care. However, we found that the record-keeping was not to an acceptable standard, as it did not conform to Association of Anaesthetists of Great Britain and Ireland guidance and we made a recommendation about this.

Recommendations

We recommended that the board:

• remind anaesthetic staff involved in this case of the importance of maintaining comprehensive records in line with the relevant guidance.

Summary

After Ms C's son (Master A) was born, he had problems taking milk and keeping it down and it often flowed from his nose when feeding. He also had a blocked nose and colic and did not sleep well. He was late to start talking, his pronunciation was poor and his speech was quite nasal. He developed behavioural problems, stemming from his frustrations about his speech. In 2011, Master A was referred to an ear nose and throat (ENT) specialist and was diagnosed with a cleft palate. Ms C then complained that her son had displayed classic signs of this condition, but multiple health professionals had failed to make a diagnosis.

Master A had a submucous cleft palate (where the muscles of the soft palate were not joined as they should be). We took independent advice from one of our medical advisers about the complaint, and accepted their advice that this type of cleft palate is invisible and would not be identified through routine mouth examinations. The adviser said that this is normally diagnosed when the child starts to speak, and speech problems are identified. We found that Master A's symptoms were investigated appropriately when Ms C raised them and in November 2011 he was appropriately referred to an ENT specialist. Due to a misunderstanding, however, this appointment was missed and there was a seven-month delay before another appointment was secured and a diagnosis made. We were satisfied, however, that the board were not responsible for the delays and that staff could not have diagnosed and treated Master A's condition any sooner.

Summary

Mr C, who had previously surrendered his driving licence for medical reasons, complained that a consultant at Dumfries and Galloway Royal Infirmary delayed in writing a report for the Driver and Vehicle Licensing Authority to confirm that he was medically fit to drive. Mr C also complained about the board's response to his complaint.

We found there was an unacceptable delay in writing the report in support of Mr C's licence application, and upheld this part of his complaint. The board explained that there was an administrative backlog, and that the report had to be written by a doctor (as opposed to an administrator). Mr C did not believe this because he was not told about the backlog when he spoke to his consultant's secretary. Our investigation established that there was a backlog, and that the report was something that only a doctor could deal with. The consultant had explained in an internal email that they could not easily delegate completion of the report, due to lack of medically qualified support.

While we took the view that it might have been helpful if the board had given Mr C some of this additional information, we did not uphold his complaint about their response, as we found that it was acceptable. The board also told us they would have expected Mr C to have been kept informed when there was a delay in replying. This did not happen, and the board did not tell us what they have done to stop this happening again. So, although we did not uphold that part of Mr C's complaint, we made a recommendation about this.

Recommendations

We recommended that the board:

• ensure that relevant secretarial and administrative staff keep members of the public updated where there is a delay in dealing with correspondence.

Summary

Mrs C complained about the care and treatment provided to her late brother (Mr A). She said that in summer 2012 his GP urgently referred him to the ear, nose and throat (ENT) department at University Hospital Crosshouse. Mr A had a history of heart disease and ulcers but over recent months had been having difficulty swallowing. An ENT consultant arranged tests, the results of which appeared to be normal, and the consultant wrote to Mr A reassuring him and saying that she did not intend to follow him up. However, Mr A's symptoms did not improve and he was seen again as an emergency in October 2012. He was found to have a large mass in his neck. This was later confirmed to be an extensive tumour, and Mr A died some seven months later. Mrs C complained that Mr A's care and treatment were inadequate and that there had been a lack of urgency to progress this and a failure to diagnose him.

We obtained independent advice on the complaint from one of our medical advisers, and took all the available information into account, including Mr A's relevant clinical records and the complaints correspondence.

Our investigation found that Mr A's lifestyle indicated he was at very low risk from this type of illness and confirmed that initial tests did not reveal anything untoward. It was also clear, however, that although the ENT consultant had later reassured Mr A about his condition, this proved to be a false reassurance. The consultant had since told the board that, with hindsight, it would have been better if she had arranged to see Mr A again. Our adviser agreed that this would have been advisable and said that, when deciding whether to see him again after the tests, the ENT consultant only had sight of a copy of her letter to Mr A's GP and not his notes, in which it was clear she had noted that she intended to see him again. Her letter did not accurately reflect what she had written in the notes and what she had intended, and so we upheld this complaint. Mrs C also complained about the board's response to her written complaint but we did not agree with her that this was inappropriate.

Recommendations

We recommended that the board:

• apologise to Mrs C for the additional stress and anxiety caused; and
• ensure that the ENT consultant discusses these events at her next formal appraisal.

Summary

Mrs C complained that the board unreasonably failed to diagnose the cause of her pain. Mrs C told us that she had experienced pain in her rib cage area since 2009 and had provisionally been diagnosed with gallstones. However, despite several hospital admissions, various tests and treatment, including the removal of her gall bladder, she remained in pain with no cause being identified. Mrs C said that the doctors treating her appeared to be accepting that her pain was unexplained and taking steps to help her cope with it, rather than seeking to diagnose the problem.

After taking independent advice from an adviser who is a specialist in pain management, we found that all the different specialists who had seen Mrs C had taken her concerns seriously and had carried out many appropriate investigations, including surgery, to determine the cause of her pain. When, however, a conclusive diagnosis for the root cause of it could not be made it was appropriate to shift the emphasis of treatment onto pain management and to refer her to a hospital pain clinic. Although Mrs C did not consider that the treatment she had received there addressed her pain, we considered it to be appropriate and in line with current medical practice. A decision to then refer Mrs C to a clinical psychologist had also been appropriate. Our medical adviser told us that there were no other investigations that the board should have reasonably considered to try to establish the cause of Mrs C's pain.

Summary

Mr C complained that there was a failure to provide his elderly mother (Mrs A) with appropriate care and treatment during two hospital admissions. Mrs A was first admitted to University Hospital Crosshouse when she fractured her pelvis after a fall at home. Mr C complained about the length of time his mother spent in the emergency department before being transferred to a ward. He also complained that her medication was changed and that she was discharged to a rehabilitation centre suffering from severe jaundice.

After taking independent advice from one of our medical advisers and our nursing adviser, we found that the time taken by medical staff to assess Mrs A and admit her to a ward was reasonable, and we identified no failings in nursing care. There was not enough evidence for us to say whether her medication was changed but we were satisfied that there was no evidence that when Mrs A was transferred to the rehabilitation centre she was suffering from severe jaundice. However, we were concerned that Mrs A did not appear to have been reviewed by a consultant within 24 hours of admission. Although our adviser said that such an assessment would not have altered the outcome for Mrs A, we considered this to be a failure of care. We were also concerned that there was a failure to assess Mrs A's bone health for possible osteoporosis (a condition that affects the bones, causing them to become fragile and more likely to break) and the reasons why she fell and suffered a fracture. In view of these failures we decided that the board failed to provide appropriate care and treatment to Mrs A during her admission.

Mrs A was readmitted to University Hospital Crosshouse the following month because her sodium level was low and she had a slow pulse. Mr C complained that medication prescribed prior to admission was changed, and that when she was transferred to Ayrshire Central Hospital she received poor nursing care.

Our medical adviser explained that there were sound medical reasons why Mrs A's medication was changed, and our nursing adviser found no evidence of any failings in Mrs A's nursing care while she was a patient in Ayrshire Central Hospital. There had been issues in relation to Mrs A's clothing, but the board had already apologised for this and taken action to address the failings identified. We were, therefore, satisfied that the board dealt with this appropriately. However, we had a number of other concerns about Mrs A's care and treatment during this admission. There was insufficient documentation in her medical notes to suggest that the assessment of her condition was sufficiently detailed and her condition severe enough to merit the medication she was prescribed for vertigo (the sensation a person has that they, or the environment around them, is moving or spinning). Also, we did not find evidence that medical staff had discussed or explained the diagnosis of vertigo or the changes to medication with her, or with Mr C. We also found that Mrs A's GP was only given a very basic level of information about her condition and treatment, with no information about her sodium level at the time of discharge or the changes to her medication. Finally, we considered that Mrs A's medical notes for this period were difficult to interpret because of poor handwriting. Because of all these issues, we found that aspects of Mrs A's care and treatment fell below a standard that could reasonably have been expected, and we upheld this complaint too.

Recommendations

We recommended that the board:

• apologise to Mr C and to Mrs A for the failings identified;
• ensure there is appropriate consultant assessment, including at weekends, for patients admitted as an orthopaedic emergency in University Hospital Crosshouse;
• ensure that the reasons why a patient has sustained a fall and the consequences of the fall are both assessed;
• ensure that medication changes are discussed as appropriate with the patient or, where appropriate, a patient's carer prior to their discharge;
• ensure that a patient's discharge summary contains all relevant information; and
• remind staff of the need to ensure that entries in a patient's records are legible.