Health

Summary

C complained about the care and treatment that their grandparent (A) received at the Royal Infirmary Edinburgh (RIE). A was admitted to the RIE following a fall. Following a period of recovery, A was discharged to their home. A was subsequently readmitted to the RIE a short time later and died in hospital following this second admission.

C complained to the board about aspects of A’s care during their first admission to RIE, including the board’s management of A’s nutrition and hydration, the physiotherapy A received, and the planning for A’s discharge, but the board did not identify any failings.

We took independent advice from a geriatrician adviser. We found that the management of A’s nutrition and hydration, the provision of physiotherapy to A, and the planning for A’s discharge was reasonable. We did not uphold C’s complaints.

Summary

C attended the A&E department at the Royal Infirmary of Edinburgh having suffered a fall and was diagnosed with muscular pain. They re-attended four months later, when a diagnosis of fractured vertebrae was made. C complained to the board that there were failures to fully investigate their symptoms and arrange appropriate x-ray imaging at the initial attendance.

When responding to the complaint, the board had initially concluded that a ‘red-flag’ symptom had been missed which should have prompted imaging. They upheld C’s complaint, apologised and outlined the steps that they would take to learn from this. They subsequently reviewed their position with neurosurgery colleagues and decided that C had been managed appropriately.

We took advice independent advice from an emergency medicine consultant. We found that C was appropriately assessed and did not meet the criteria in the relevant guidelines for their injury to have been considered high-risk and requiring imaging. We did not uphold the complaint. We found that we weren’t critical of the board for reviewing and revising their decision. However, we were critical that they had not communicated this to C and shared recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to inform them that they had changed their position, as outlined in their final complaint response. 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 follow-up on the findings of complaint investigations and ensure that any identified learning actions are taken forward. If the board decide against taking promised actions, and particularly if this is as a result of a change / retraction.

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 on behalf of their partner (A) about the care and treatment provided by the board when A had hip replacement surgery. Specifically, C complained about the management of A’s pain in the post-operative period. The board acknowledged the discomfort experienced by A, but when it became apparent that surgeons could not manage A’s pain effectively, the Pain Management Team was involved. The board considered the care delivered following surgery, and in reducing medication after discharge, was reasonable.

We took independent advice from an anaesthetics and pain management adviser. We found that whilst pain management in the post-operative period is challenging, the board’s management of A’s pain was reasonable following surgery. We did not uphold this aspect of the complaint.

Additionally, we found that, with respect to reducing A’s medication, the advice provided by the board to A following discharge was appropriate. On this basis, we did not uphold this aspect of the complaint.

Summary

C complained about the care and treatment provided to their sibling (A) by the practice. A had previously been diagnosed with breast cancer a number of years ago. A became ill and attended the practice on several occasions over the year. The GP considered A had gastroenteritis (inflammation of the stomach and intestines). A’s symptoms persisted and A was referred to hospital for a colonoscopy (examination of the bowel with a camera on a flexible tube). The request was rejected. A presented at the practice with the same symptoms on two further occasions and the practice made an urgent ‘suspicion of cancer’ referral to the health board. A scan showed a tumour attached to A’s right kidney. A died some months later.

C complained that despite A’s multiple attendances at the practice and concerns that the cancer had returned, the practice failed to reasonably respond to A’s worsening condition and delayed or failed in carrying out appropriate investigations and associated tasks.

We took independent advice from a GP adviser. We found that initially there was no unreasonable delay in the practice recognising the seriousness of A’s symptoms and that the appropriate referrals for a colonoscopy and ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) were made. We also noted that it would not have been appropriate for the practice to have undertaken a CEA blood test (carcinoembryonic antigen test, a blood test used to help diagnose and manage certain types of cancers) and that the actions of administrative staff in filing away test results was appropriate and in line with established good practice.

However, we found that there was a failure to include clinically important information in referrals and in consultation documentation, and that there was a delay in sending A’s suspicion of cancer letter. We also found that the practice should have considered undertaking some additional blood tests when it was clear A was deteriorating, or documented the awareness of any blood tests undertaken by the hospital during this period. Therefore, on balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of the complaint. 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:

• Appropriate and timely blood tests should be considered when it is clear a patient is deteriorating in cases similar to A’s or awareness of any blood tests undertaken e.g. by hospital documented.
• Notes of consultations should include appropriate detail including a description of the length and progression of symptoms along with any potentially relevant past history.
• Referral letters should include a clear history, examination and relevant background information.

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 was referred by their local health board ophthalmology (the branch of medicine that deals with the anatomy, physiology and diseases of the eye) department to the general hospital for specialist eye surgery. C underwent a vitrectomy procedure (the surgical operation of removing the vitreous humour from the eyeball) which they felt was not managed appropriately as their retina was still detached following the procedure and they had to undergo further surgery from an independent health provider. The board felt that they had provided an appropriate standard of care and treatment to C.

We took independent clinical advice from an ophthalmology adviser. We found that there were no concerns about the standard of treatment which was provided to C. C had suffered a serious eye injury and although the retina was not fully reattached during surgery, this was a recognised complication of the surgery, and that further surgery would be required at some point. We did not uphold the complaint.

Summary

C complained about the care and treatment provided by the board to their parent (A), who was admitted to hospital with a suspected liver problem. Ascites (a build-up of fluid in the abdomen) was diagnosed and paracentesis (a drain of the fluid) was performed, during which it was noted that A had accidentally bumped the drain. The following day A reported being in pain and, after a CT scan, it was determined that A was suffering from an un-operable arterial bleed. Shortly thereafter A died.

C complained that A’s consent was not properly obtained, that staff had failed to carry out the drain procedures reasonably, that A’s pain was not managed appropriately, that a CT scan was delayed, that communication from the board had been poor and inconsistent and that the level of review undertaken after the incident was not sufficient.

We took advice from an independent medical adviser in gastroenterology (medicine of the digestive system and its disorders). We found that the timescale for the CT scan was reasonable, that pain medication was appropriate, that the case had ultimately been appropriately reviewed and that the drain procedure appeared to have been carried out by appropriately trained staff under adequate supervision.

However, we found a number of failings. Firstly, the board had obtained verbal consent but failed to adequately record this. Secondly, the board’s complaints response had unreasonably focused on A having bumped the drain as being the cause of the arterial bleed. This was something that could not have been known with any certainty. Additionally, this explanation was not consistent with the post-mortem examination and internal case review, both of which found that the more likely cause of the bleed was as a recognised complication of the drain insertion. Therefore, we upheld these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C 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 and their families should be given clear, consistent and accurate information about the patient's care and treatment, including any complications. Complaint responses should be accurate, and evidence based.
• In future, the board will get formal written consent from patients for this type of procedure. They will also prepare a consent booklet, which will be reviewed by their gastro clinical governance group and their clinical guidelines group.

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 orthodontic care (dentistry dealing with the prevention and correction of irregular teeth) provided to their child (A), particularly that A's treatment had been unreasonably discontinued. The dental practice's decision to discontinue was based on a failure to comply with the requirements of the orthodontic treatment. C complained that the orthodontist had not raised any significant concerns previously, and that there had been a lengthy period without review due to Covid-19 restrictions.

We took independent clinical advice from an orthodontic adviser. We found that the records evidenced only intermittent or periodic poor oral hygiene, as opposed to the consistently poor oral hygiene noted by the orthodontist. We also found that there was evidence of valid clinical grounds to support the stoppage of A’s treatment. However, we also found that there were significant failings regarding the way the decision was communicated.

At the last appointment A attended, the records give the expectation that treatment was continuing. C tried to contact the orthodontic practice following this appointment to find out when the next review appointment would take place. When they did not receive a reply they submitted a complaint, the response to which communicated the decision to discontinue treatment. This was several months after A had last been seen. The orthodontist failed to clarify in the response why they had not replied to C’s communication after the last appointment, and it was not made clear specifically when it had been decided A’s treatment should be discontinued. We found that the orthodontist’s actions were not compliant with General Dental Council standards for communicating with patients. We found that the orthodontist’s decision to discontinue A’s treatment was unreasonable, particularly in relation to the way it was communicated. As such, we upheld the 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:

• Communication with patients and/or their guardians should be carried out and documented in line with the relevant standards (Standards for the Dental Team, GDC).
• The orthodontist needs to ensure that complaints are handled in line with the NHS Complaints Handling Policy. This requires a response to be issued within twenty working days of receipt of a complaint, addressing all the issues raised and showing that they have been fully and fairly investigated.

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 there was an avoidable delay by staff at a community hospital in referring them to the specialist clinic at the local general hospital when they suffered a detached retina. C attended four consultations at the community hospital before they were referred to the specialist clinic and they felt that the delay had had an adverse effect on their sight. The board maintained that appropriate treatment was provided.

We took independent advice from an ophthalmology (the branch of medicine that deals with the anatomy, physiology and diseases of the eye) adviser. We found that the clinicians at the community hospital had taken advice from specialists at the general hospital and had monitored C’s condition by regular ultrasound scans. When C’s condition deteriorated and evidence of retinal detachment was found on a scan, C was referred to the specialist for continuing treatment. We therefore did not uphold the complaint.

Summary

C complained to the board on behalf of their partner (A) about the length of time taken to arrange a lumbar puncture test (LP, a procedure used to collect a sample of fluid from the spine) following assessment by a neurologist (specialist of the nerves and the nervous system). C had regularly contacted the board requesting an update on C’s appointment and eventually decided to complain when they were told to ask A’s GP to re-refer them. On complaining, A received their LP appointment. The board advised that the delays had been caused by the Covid-19 pandemic and that A had now been appointed to see a neurology consultant.

We found that the board had separate processes in place for arranging LPs depending on whether a patient was seen by a locum consultant or a member of the board’s own staff. As A was seen by a locum consultant, they were required to be added to an anaesthetist’s (administer of drugs) list which ran every three-four months. Had they been seen by the board’s own staff, they would have arranged the LP test directly without the need to refer them to a separate list. In A’s case, the original anaesthetist’s list that they were appointed to was cancelled, as was the second due to the onset of the pandemic, which meant that A was required to wait 10 months for this test. We upheld this complaint.

C also complained that the board failed to provide pain relief to A while waiting for the LP test. While we considered C’s expectations to be reasonable in respect of the results of the LP test confirming A’s diagnosis and informing decisions about future care and treatment, including management of their pain, we considered that this aspect of their care to remain the responsibility of A’s GP at this time. As such, we did not uphold this part of C’s complaint.

Finally, we found that the board’s complaint handling was unreasonable, particularly in relation to the failure to act on the lack of equivalence in service provision despite this problem being known following the board’s own investigation of C’s complaint. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to arrange the LP test reasonably and for failing to reasonably respond to their complaint. 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 implement a sustainable model for listing the patients of locum doctors to ensure that they timeously receive LP tests. This should include a contingency plan to prevent long delays for patients when lists are cancelled.

In relation to complaints handling, we recommended:

• The board’s complaint handling monitoring and governance system should ensure that complaints are appropriately investigated and that failings (and good practice) are identified and learning from complaints are used to drive service development and improvement. All staff dealing with complaints should be familiar with the Model Complaints Handling Procedure, understanding the importance of communication and the need to demonstrate thorough investigation and action taken on the points raised.

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 provided to their late parent (A) from the board during a hospital admission. C complained that A had been discharged from hospital when it had been unsafe to do so, that staff had failed to insert an intravenous line so that A could receive fluids, that A had developed a pressure sore on their sacrum (a bone in the spine), and that insufficient investigations had been carried out to establish the cause of A’s refusal of treatment.

The board stated that A had received fluids intravenously on admission but that their cannula (a tube that can be inserted into the body) had become blocked. Further unsuccessful attempts were made to reinsert the cannula before A declined any more attempts to be made. A also had refused to accept oral treatment and did not wish to undergo investigations to establish cause of their illness, preferring instead to be discharged home. The board also stated that A had been non-compliant and had not wished to change position in bed resulting in the development of a pressure sore, for which arrangements were put in place with district nurses upon A’s discharge.

We took independent advice from a consultant geriatrician. We found that the investigations the board had carried out to establish the cause of A’s illness had been reasonable as had the overall treatment provided during A’s admission. We noted that the records showed A had declined several attempts to treat their symptoms and carry out further investigations and that there was no evidence in the available records to indicate that A had lacked capacity to make decisions about the medical treatment that they wished to receive. In relation to A’s discharge, the records also showed that the board had requested an assessment of A to be carried out by their Integrated Assessment Team but that this could not be completed due to A leaving the hospital. We found that management of A’s pressure sore had reasonable.

For these reasons, we did not uphold the complaint.