Health

Summary

C, the parent of A, complained about a delay in diagnosing A's thyroid cancer. A had an emergency admission to Dumfries and Galloway Royal Infirmary with acute tonsillitis and a lump was found on their neck. This lump was subsequently excised four months later, and cancer was diagnosed the following month. C complained that no prior indication had been given that cancer was suspected, and that the delay in diagnosing this led to unnecessary operations. They also complained about a subsequent delay in informing them about identified nodules on A's lung that were being monitored.

The board told us that they recognised that an earlier biopsy could have led directly to definitive surgery, without the need for further investigations or procedures and ultimately to a quicker resolution for A. They confirmed that they developed a new neck lump clinic as a result of this complaint. We took independent advice from a head and neck surgeon. We noted that A should have had an urgent needle biopsy at an earlier point in time. This would have led to an earlier diagnosis and less surgery. We noted that an excision should only have been considered if a diagnosis was not possible from the needle biopsy. Therefore, we upheld the complaint that there was an unreasonable delay in diagnosing A's cancer. We considered that the new neck lump clinic was the best way to avoid this happening again. While we were assured that the delay did not have an impact on A's prognosis, we noted that it will have added to the distress for A and the family.

In relation to C's concerns about not being advised sooner that cancer was suspected, we noted that cancer did not appear to have been considered earlier. We were, therefore, unable to conclude that there was a failure to communicate a suspicion of cancer. We noted that the board had already acknowledged that they did not make A aware of the lung nodules when they were identified. Therefore, on balance, we upheld the complaint that communication was unreasonable. The board had already apologised for this and they told us that they had revised their process to require clinicians to copy GP letters to patients.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for the unreasonable delay in diagnosing A's cancer. 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:

• Neck lumps should be investigated with a needle biopsy in the first instance, and an excision should only be considered if a diagnosis is not possible from the needle biopsy. This should be undertaken urgently until cancer is excluded. This case should be discussed at the department's morbidity meeting and the findings of this investigation fed back to relevant staff in a supportive manner for reflection and learning.

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 said that they had been incorrectly diagnosed with Avoidant Personality Disorder (APD). C said that the board had failed to carry out a proper assessment of their presenting symptoms and incorrectly relied on historic information in reaching their diagnosis. They complained that the board's diagnosis had prevented them from accessing appropriate supports and treatment for other comorbidities.

According to NHS Inform, based on statistical information from England, personality disorders can affect one in 20 people and can be very difficult to live with.

In this case, we took independent advice from an adult psychiatry adviser. We considered that the board's diagnosis had been reasonable, however the possibility of a depressive disorder co-existing with this disorder's traits, and a physical disorder contributing to mood change, had not been adequately investigated. We also found that the board did not have an appropriate care pathway for APD, that staff had been unaware of it and that there was a lack of continuity in the board's procedures for requesting both internal and external opinions. Therefore, on balance we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to carry out a reasonable assessment of their symptoms. 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 arrangements for requesting second opinions within the organisation, and external opinions, should be clarified.
• The care pathways for Personality Disorder should be clarified, and in particular the treatment options of Cluster C disorders such as Avoidant (Anxious) Personality Disorder.

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 Scottish Ambulance Service's (SAS) failure to take appropriate action in response to patient A's symptoms. A had been ill for approximately two days with a high temperature, fever, followed by diarrhoea, trouble passing urine, extreme pain, breathlessness and struggling with mobility. When the SAS crew attended to A at home, an assessment was carried out and senior clinical advice was sought from the out-of-hours GP. It was decided that A did not require to be admitted at that time.

The following day A was admitted to hospital and later died from sepsis (blood infection). C complained that the SAS crew failed to recognise the signs of sepsis and to take the appropriate action in response to their symptoms.

As part of our investigation, we reviewed the relevant records and sought independent advice from a registered paramedic. We found that the SAS crew carried out an appropriate assessment of A's condition and that there was sufficient evidence that the possibility of sepsis was considered. We found that the SAS took the appropriate action in response to A's symptoms and we did not uphold the complaint.

Summary

C's child (A) had complex needs as a result of a brain injury sustained when they were four years old. Given A's care needs, they had an Anticipatory Care Plan (ACP) in place which was reviewed regularly.

A was admitted to a general ward at Ninewells Hospital with a high temperature and was subsequently moved to a high dependency unit. A died three days following admission.

C complained about the inappropriate use of Hi-Flo Nasal Cannula Oxygen (high-flow oxygen, a form of respiratory support) despite concerns raised at the time. C complained that incorrect decisions were taken with respect to A's care and treatment, including that clinicians did not have appropriate regard to the ACP that was in place.

In response to the complaint, the health board carried out a Mortality Review and shared its findings with C. The findings were that care was maximised in the High Dependency Unit as it was not felt A would survive admission to Paediatric Intensive Care Unit, and that this decision together with the decision not to intubate was made with C's input. The variation in care from the ACP was discussed with C and highlights plans are flexible.

C complained to our office that clinicians failed to follow the ACP, that they did not take their views into consideration and that A died of carbon monoxide poisoning as a result of the decisions made in relation to A's treatment and care.

We took independent advice from a consultant paediatrician. We found that there was good documentation evidencing that clinicians had discussed A's care with C, including decisions not to intubate A. We considered treatment with high-flow oxygen was reasonable in the circumstances. Whilst the ACP was not followed, and the board identified this, the ACP is not a legally binding document and the decisions to deviate from the ACP were reasonable in the circumstances. A's cause of death is consistent with the evidence within the medical records. We concluded that A's care and treatment was reasonable and did not uphold the complaint.

Summary

C attended the A&E at Ninewells Hospital with back pain and leg weakness, and was discharged with a diagnosis of suspected sciatica (back and leg pain caused by irritation or compression of the sciatic nerve). C had attended a neurology (the science of the nerves and the nervous system, especially of the diseases affecting them) out-patient clinic earlier that day regarding a separate matter, and the neurologist had noted a foot drop (a muscular weakness or paralysis that makes it difficult to lift the front part of the foot). C complained that the A&E failed to accurately assess them and refer them on to neurosurgery (surgery of the brain or other nerve tissue). C was assessed by neurosurgery four days later, following an urgent GP referral, and was diagnosed with disc prolapse (ruptured disc in the spine) and nerve compression (direct pressure on a nerve) requiring surgery that same day.

The board advised that, while the A&E doctor noted reduced power in C's left leg, they did not feel that foot drop was present and that they felt that sciatica was the most likely diagnosis. The board noted that the neurologist's observation that C had foot drop was not based on a physical examination, whereas the A&E doctor documented a physical examination. The board also noted that local neurosurgical referral guidelines state patients with back pain and sciatica with neurological deficit should be referred to physiotherapy prior to referral to neurosurgery. They concluded that C received appropriate care that was in keeping with relevant guidelines.

We took independent advice from a consultant in emergency medicine. We found that C's assessment and management in the A&E was reasonable and appropriate. We found that the mild weakness documented on assessment in the A&E was not in keeping with a foot drop and that it did not indicate that a neurosurgical referral was required at that time. The A&E discharge letter documented that C was advised to see their GP, and we noted that it was reasonable and in line with common practice for the A&E to ask the GP to follow-up rather than refer directly to physiotherapy. Therefore, we did not uphold the complaint.

Summary

C complained about the treatment provided to their late partner (A). A had reported a number of symptoms by telephone to their practice but they had not made arrangements to see them in person and C said that, as a result, they did not receive appropriate care and treatment. A reported symptoms over a period of time. However, A began to have seizures and tests revealed that A had lesions on their brain. C believed that the practice should have acted earlier and that A's condition could have been diagnosed sooner.

We took independent advice from an adviser who is an experienced GP. We found that the practice had provided A with appropriate care and treatment based on their reported symptoms. There was no evidence that A required an earlier face-to-face appointment or that red flag symptoms were missed.

We did not uphold the complaint.

Summary

C complained of a delay in diagnosing their late partner (A)'s cancer by medical staff in University Hospital Monklands. A was diagnosed with a rare cancer and died three weeks later. They had been unwell for around five months and had multiple hospital attendances and admissions. C complained that appropriate tests weren't carried out in a timely manner, and that A was misdiagnosed and treated for potential illnesses they did not have.

We took independent medical advice from a consultant in respiratory and general medicine. We found that A's case was complex and unusual and that it was reasonable to consider other diagnoses more likely than cancer, and to treat these accordingly while investigations continued. However, we found that reasonable action was not taken to manage the pleural effusions (fluid around the lung) that A initially presented with. Guidelines indicate that a fluid aspiration (removal of a small amount of fluid for testing) should have been arranged to rule out infection in the pleural space (cavity between lungs and chest wall). This was not arranged until almost eight weeks later. When this was done and the result was inconclusive, guidelines recommended that a biopsy be carried out and this wasn't done either. In addition, an ultrasound scan the following day reported ascites (fluid within the abdomen), and again a fluid aspiration was indicated but wasn't carried out.

A biopsy via thoracoscopy (keyhole camera into the pleural space) was not carried out until a further 14 weeks later. A's cancer was diagnosed thereafter. We found that there were earlier indications for a thoracoscopy and missed opportunities to diagnose A's cancer from the time of their initial presentation. While we acknowledged that an earlier diagnosis was unlikely to have altered A's prognosis, we noted it would have enabled palliative care to commence and allowed the family time to prepare and make the most of the time they had left together. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to carry out appropriate investigations in a timely manner, and for the consequent delayed diagnosis and impact of this on A and the family. 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:

• Adherence to relevant national guidelines on managing pleural disease and managing ascites. Appropriate investigations carried out as and when indicated, leading to timely diagnosis.

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 made a complaint about their late parent (A)'s discharge from University Hospital Hairmyres. C believed that A was not fit to be discharged and that this resulted in A having a fall, and sustaining an injury which then contributed to A's death.

We took independent advice from a physiotherapy adviser and a consultant physician and geriatrician (a speciality focussing on the health care of elderly people). We found that a comprehensive geriatric assessment was not carried out during A's admission. Given that this is a requirement outlined in the Healthcare Improvement Scotland (HIS) Care of older people in hospital standards, we considered it was unreasonable that no assessment appears to have been carried out. This may have provided a more comprehensive view of the issues affecting A.

We also found that A's case was not discussed at a Multidisciplinary team (MDT) meeting prior to A's discharge. If this meeting had taken place, the MDT could have considered whether A would have benefited from further rehabilitation (either in hospital or in the community).

Given that an MDT meeting did not take place prior to A's discharge, and given the lack of a comprehensive geriatric assessment in line with HIS standards, on balance, we considered the decision to discharge A was unreasonable. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not carrying out a comprehensive geriatric assessment during A's admission and for not discussing A's case at a Multidisciplinary team (MDT) meeting prior to their discharge. 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 have access to MDT meetings including all appropriate specialties to discuss patients on geriatric units who have MDT input.
• Older people presenting with frailty syndromes should have prompt access to a comprehensive geriatric assessment in line with Healthcare Improvement Scotland standards.

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 power of attorney (POA) for their late spouse (A) and complained about the care and treatment provided to A when they were admitted to hospital from a care home. During their admission, A was detained under the Mental Health (Care and Treatment) (Scotland) Act 2003 due to the severity of their dementia. A's health deteriorated and they died in hospital. C complained about various aspects of A's medical care, nursing care and staff's communication with C.

We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly) and a registered nurse. In respect of C's concerns about the medical care provided, we found that while the treatment provided in the earlier part of A's admission was reasonable, staff should have sought C's views about the additional investigations undertaken immediately prior to A's death. We upheld the complaint on that basis.

We concluded that while the nursing notes could have been more explicit on some aspects of A's care, the nursing care overall was of a reasonable standard. We also concluded that the communication with C about A's detention and deterioration was reasonable. We did not uphold these complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide a reasonable standard of medical treatment to A. 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 that carers are consulted when making decisions about medical treatment.

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, a support and advocacy worker, complained on behalf of their client (A). A presented to the practice with symptoms of stomach pain and upper and lower backpain. Following several consultations, a GP referred A for an abdominal and renal ultrasound on a routine basis. A was contacted by the hospital with an appointment and was advised that their GP could expedite this if they considered it appropriate. A was referred on an urgent basis by the practice to gastroenterology (specialism of the treatment of conditions affecting the liver, intestine and pancreas) which later confirmed A's diagnosis of cancer.

A complained to the practice that they had failed to expedite the referral despite their worsening symptoms. A believes that if they had been referred to secondary hospital services punctually and had obtained a timely diagnosis, their medical treatment would not have been as invasive and that the risk of cancer spreading to other organs would have been reduced.

In response to the complaint the practice said that an urgent referral was sent to gastroenterology when it was clear that A's symptoms had progressed. A was dissatisfied with the practice's response and C brought the complaint to our office on A's behalf.

During our investigation we requested independent advice on the practice's consultations with A and the arrangements for referring A for further investigations. We found that the decision to refer A initially on a routine basis for an ultrasound was reasonable, given A's symptoms. We found that the medical records indicated consultations with A were reasonable and on the basis of the progression of A's symptoms, there was no unreasonable delay in the urgent referral to gastroenterology being made. We found that the referrals were reasonable and there was no unreasonable delay in making them, as such we did not uphold the complaint.

We provided some feedback to the practice on the management of A's pain.