Health

Summary

C, an advocate, complained on behalf of their client (B) about the care and treatment provided to B's late spouse (A). A had attended their GP practice complaining of pain between the shoulder blades and breathlessness on exertion and was seen by a nurse practitioner. The nurse referred A to hospital for a chest x-ray which they received the next day. A then received further x-rays throughout the month following attendances at A&E. They were referred to another hospital where they were later diagnosed with advanced lung cancer.

B complained about the about the nurse's assessment and that the practice failed to follow up on the chest x-ray they referred A for, and failed to follow up on their various attendances at A&E. Had they done so, B considered that A might have been diagnosed sooner.

We took independent advice from a nurse and a GP. We found that the assessment by the nurse practitioner was reasonable and the decision to refer A for chest x-ray and spirometry (a simple test used to help diagnose and monitor certain lung conditions) was appropriate.

In relation to the x-ray taken after the nurse's referral, the results recommended referral to respiratory medicine but the practice did not receive the report until after A's death. We found that it was the responsibility of radiology (specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) to send the x-ray report to the GP, which in this case had not happened and would not expect a practice to chase up records. We also noted that the practice now log all investigation requests and check that results have been returned, which is good practice and above the standard level of care.

In relation to the various attendances at A&E, we found that it is not expected of the practice to follow up on these attendances. There was no mention in the discharge letters sent to the GP of any action required.

Therefore, we did not uphold C's complaints.

Summary

C complained about the care and treatment that their parent (A) received from the board. Following surgery to remove bladder lesions, A experienced severe pain and urinary problems. It was established that they had a bladder perforation. C complained that, whilst A's consultant initially accepted and apologised for the fact that A's bladder was likely perforated during surgery, the board subsequently backtracked and suggested that there could have been a number of causes. C did not consider that their family had been given a clear explanation as to how A's bladder had been perforated.

A subsequent review of A's case established that they had cancer invading their bladder muscle. The cancer could not be treated with chemotherapy or radiotherapy and staff had discussions with A regarding the difficulties associated with attempting surgery in light of their other existing medical conditions. A was readmitted to hospital via A&E the following month, due to bladder spasms and catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) pain. A CT scan was carried out and A was admitted to a ward for ongoing monitoring and treatment. A's pain worsened and further scans showed that the cancer had spread to their lungs. Surgery was no longer an option and A died shortly afterward.

C complained that the communication from the urology staff (specialists in the male and female urinary tract, and the male reproductive organs) during A's hospital admissions was poor and that there was an unreasonable delay to A and other family members being told the extent of A's condition.

We took independent advice from a consultant urologist. We considered that, when responding to C's complaint, the board sought to provide a detailed description of events and a clearly set out explanation as to the potential causes of A's bladder perforation. That said, we found that information provided by C was not taken into account and, had it been, a clearer explanation could have been provided by the board. Therefore we upheld this aspect of C's complaint.

We found that A did not require routine input from urology. Their day-to-day care in hospital was managed reasonably by gastroenterology (specialists in the diagnosis and treatment of disorders of the stomach and intestines), with input from urology as required. We were satisfied that A's urology investigations took place in good time and a reasonable management plan was put in place for their ongoing urology input. Overall, we found that the communication from the urology staff to be reasonable. We did not uphold this aspect of C's complaint.

A had a rare and aggressive form of cancer. We accepted evidence from the board that earlier scans showed evidence of changes that were visible, but not identified. We concluded that, whilst the treatment options available to A may not have been any different, had the changes been identified earlier, they may have been given details of their cancer and prognosis sooner and this may have given A more time to prepare and make arrangements. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for the failings identified 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.

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. C had experienced severe nausea but initial investigations found no definitive cause for their symptoms and a presumed diagnosis of irritable bowel syndrome (IBS, a condition of the digestive system that can cause stomach cramps, bloating, diarrhoea and constipation) was made. C said that they were provided with medication but this had little effect.

C developed severe abdominal pains later the same year which required immediate surgery and initially appeared to recover well. However, their abdominal pains returned a few months later and they required a hospital admission. Further surgery was carried out, establishing and resolving the root cause of the pain.

Whilst C's pain resolved following the second surgery, they raised a number of concerns regarding the care and treatment provided by the board, delays to diagnosing the cause of their symptoms and inaccurate documentation of the procedures that they had had.

We took independent advice from a consultant gynaecologist (a doctor who specialises in the female reproductive system). We found that the initial view that C's symptoms were being caused by a bowel condition was reasonable and that IBS was a reasonable working diagnosis while tests were carried out to confirm or rule out other possible causes of their nausea. We were satisfied that the working diagnosis and the focus of investigations changed when C's symptoms escalated. We were also satisfied, following the recurrence of their abdominal pain, that the board followed a reasonable and recognised pathway to establishing the cause of C's pain. Therefore, we did not uphold these aspects of C's complaint.

We were critical, however, of a number of errors in C's medical records, including details of another patient's procedures being misfiled in C's notes. We upheld this aspect of 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.

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 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.