Health

Summary

Mr C complained that the board had failed to return his in-the-ear hearing aids to him after they were repaired and told him they must have been lost in the post. He said they then decided not to provide the same type as a replacement, and told him he would be given behind the ear aids instead. When Mr C complained about this, he said the board failed to fully evidence or explain why he could no longer have in-the-ear hearing aids.

We took independent advice from one of our medical advisers on this case and she said that the board's guidelines for hearing aid provision were arrived at properly, were ones they were entitled to apply and that the decision-making process was appropriate and in accordance with the guidance. She said that Mr C did not meet the criteria for in-the-ear hearing aids set out in the guidance.

In terms of their response to Mr C’s complaint, we considered that the board had provided a full and reasoned explanation of why Mr C no longer qualified for in-the-ear hearing aids, that their letters had been detailed and noted that they had offered to meet with Mr C to discuss his concerns.

However, we accepted that had Mr C’s original hearing aids not been lost in the post then he would not be in his current position. We also noted that he had said that the board had previously lost his hearing aids and moulds and we did not see any evidence that the board disputed this. Although, therefore, we did not uphold Mr C's complaints, we considered it reasonable that the board could and should have provided a more secure and reliable means of returning Mr C’s repaired hearing aids and because of this we made a recommendation.

Recommendations

We recommended that the board:

• provide Mr C with replacement in-the-ear hearing aids.

Summary

Mrs C's late husband (Mr C) was admitted to hospital, having been referred there by his GP for rectal bleeding and diarrhoea. His symptoms were attributed to his known history of diverticulitis (a common disease of the digestive system), but he was also found to have an abdominal aortic aneurysm (ballooning of part of the aorta, the body's largest artery). His symptoms settled and he was discharged after three days. However, a CT scan (a special scan using a computer to produce an image of the body) carried out during his admission showed that his aneurysm required urgent treatment and he was readmitted within two weeks for surgery, in which a graft was used to repair the aneurysm.

Mr C recovered well and was discharged six days later with arrangements for him to be reviewed in another six weeks. Around five weeks after his surgery, however, Mr C began coughing up blood. He attended the accident and emergency department, and was readmitted to hospital. Tests were carried out to check for a blood clot in his lungs or a chest infection, and he was treated for a presumed chest infection. Mr C's kidney function was also impaired and he became septic (with infection in the bloodstream), but the cause of the sepsis was unclear. He was referred for review by a surgeon who arranged another CT scan. This showed evidence of air pockets around the graft that had been used during his aneurysm repair. Mr C was treated with antibiotics, then had further surgery to remove and replace his infected graft. After the operation,

Mr C was taken to the intensive care unit (ICU) and high dependency unit (HDU), but was transferred back to the main ward three days after his operation. He developed oedema (swelling) and kidney failure. He was transferred back to the ICU, but suffered two heart attacks and died three weeks after the surgery.

Mrs C complained that the board discharged Mr C too soon after his initial operation. She also felt they failed to identify the source of his infection, despite his recent operation wound being a likely site and that the vascular surgeon who carried out his operation was not informed of his re-admission soon enough. Mrs C also complained that Mr C was transferred out of the ICU/HDU too soon.

After taking independent advice from our medical advisers, we upheld Mrs C's complaints about her husband's first discharge from hospital, and the move out of ICU/HDU, but not her other complaints. We found that the board failed to follow their own discharge planning policy properly and, although there was no clear evidence to suggest that Mr C was not fit for discharge after the first operation, a lack of records meant we were unable to be certain of this. We noted that the board took appropriate action when Mr C developed a rash over his entire body, but we criticised the decision to transfer him back to the main ward after his last operation. Our adviser said that his fluid balance was poorly managed and that staff on the main ward would not have been qualified to provide the close monitoring and treatment that he required. We were, however, satisfied that the board took reasonable steps to identify the source of Mr C's infection. As he initially presented with respiratory symptoms, there was no cause to involve the vascular surgeon or to investigate his operation site as the source of infection. However, as potential sources were ruled out, the vascular surgeon was contacted for his view.

Recommendations

We recommended that the board:

• audit their performance in relation to their discharge from acute care policy with particular emphasis on record-keeping and ensuring patients are reviewed daily;
• apologise to Mr C's family for the additional discomfort caused by his premature discharge to the main ward; and
• arrange for their ICU and HDU staff to review Mr C's case with specific reference to fluid balance management to identify any points of learning.

Summary

Miss C's mother (Mrs A) was admitted to an island hospital with pancreatitis (inflammation of the pancreas), where her condition deteriorated overnight. The next day, it was identified that she was developing organ failure, as a complication of the pancreatitis. She was transferred to a mainland hospital in another health board area. Mrs A died around sixteen days later from multiple organ failure.

Miss C complained about the care and treatment provided to her mother in the island hospital in the two days before she was transferred. After taking independent advice from one of our medical advisers, we found that a prompt and appropriate detailed medical assessment was completed when Mrs A was admitted. There was clear documentation of her vital signs, current drug treatment, physical examination and initial blood tests. The initial diagnosis of acute pancreatitis was correct and was made within a very short time. We also found that the later care and treatment provided to Mrs A was reasonable and appropriate, as was the attention to her pain relief. The deterioration in Mrs A's condition was due to the development of increasingly severe pancreatitis, complicated by early organ failure, rather than inadequate medical care. We did not consider that there were any clinical failings that impacted adversely on Mrs A, and our adviser said that no other specific treatment could have been offered at that time that might have changed the course of events.

Miss C also complained that the board failed to provide her and her sibling (who were both teenagers) with sufficient support when their mother was transferred to the mainland hospital. Miss C decided not to travel with Mrs A when she was transferred by ambulance, and said that when she and her sibling later went to visit their mother, they had to stay in a bed and breakfast without any support.

We found that although it would not have been appropriate for the board to pay their costs, they should have provided Mrs C’s children with advice on how to try to get help with these. We also found that Miss C was not given enough information about her mother’s prognosis to make an informed decision about whether to travel with her in the ambulance. Having carefully considered this matter, we upheld the complaint that the board had not provided Mrs A's children with adequate support when it was decided that she should be transferred.

Recommendations

We recommended that the board:

• issue a written apology to Miss C for the failure to provide her with adequate information about her mother's prognosis and for failing to provide her with adequate advice on how to try to obtain further support with travel costs; and
• take steps to ensure that relatives are given adequate information about how to try to get help with the costs of visiting patients who are transferred to hospital on the mainland.

Summary

Mr C was being treated for HIV (Human immunodeficiency virus - the virus that causes acquired immunodeficiency syndrome (AIDS)). He was unhappy because the board sent his medication to a family member's home, rather than to his medical practice as requested. A family member opened the package and became aware of Mr C's HIV status. Mr C had not discussed this with his family, and it caused him and his family a great deal of upset and difficulty.

He complained to the board, who investigated and found that when he had asked for his medication be sent to his practice (which was in another board's area) the board's pharmacy services had said that they could not send medication to a GP outwith their board's area. Nursing staff had then contacted Mr C's consultant for advice, who said that the medication should be sent to Mr C's home address. However, pharmacy services unfortunately had the address of a family member on their database rather than Mr C's own address. They did not contact Mr C to check that the address was correct or that he was happy for the medication to be posted directly to him. As a result of these failings, the board upheld his complaint, apologised to him, and advised that they had introduced procedural changes to prevent this happening again.

Mr C remained unhappy and brought the complaint to us. We investigated and found that the board's explanation of what went wrong was correct. As they failed to check Mr C's address details or seek his consent to send the medication to his home address, we upheld his complaint. We also obtained details of the safeguards introduced to ensure that this does not happen again, and were satisfied that these were appropriate. For this reason, and because they had already apologised to Mr C for the significant distress this matter had caused, we made no recommendations for further action.

Summary

Ms C is a transgender woman undergoing gender reassigment (a process of changing from man to a woman). She complained that the assessment process for acceptance for gender reassignment surgery took too long and was unreasonably delayed. She started going to the relevant clinic, attending regularly over the following three years. She was referred for a range of additional treatments including hormone therapy, plastic surgery and speech therapy. She sometimes presented at the clinic as a man and sometimes as a woman, but consistently said she was keen to seek gender reassignment surgery.

After three years Ms C was given a referral for gender reassignment surgery in the UK. Ms C then said she preferred to have this abroad, asked for a referral, and withdrew from the service.

In considering this complaint, we took independent advice from our psychiatric adviser, who reviewed all the consultations that Ms C had as she progressed towards referral for surgery. While he acknowledged that it had taken some time for Ms C to gain her referral, he did not identify any specific delays on the part of the board. The timescales involved were partly due to referrals to other services and partly due to inconsistencies in the way Ms C was presenting at the clinic.

Ms C also complained that the board unreasonably refused to refer her for surgery abroad. She said that the criteria for referral were the same, and she would be paying for the surgery. The board said that the decision not to refer Ms C was taken on policy grounds, as international referrals are only made when specialist skills are not available in the UK. Our adviser noted that it would have been appropriate to make an exception to policy on this occasion, given that payment for surgery was not an issue, and we upheld the complaint. However, we noted that before gaining a new referral, Ms C would need to provide evidence that she was ready for surgery now, as she does not currently meet the referral criteria because she withdrew from the service.

Ms C also complained about the standard of plastic surgery on her jaw. She said that it had left her jaw heavier on one side, and that this was deliberate on the part of the surgeon. We took independent advice on this from a facial surgery adviser, who found that the technique used during surgery was appropriate and that the results were of an acceptable standard. He noted that all faces are asymmetric and that patients who have had plastic surgery are much more aware of their appearance after surgery than they were before.

Finally, Ms C complained that there were factual inaccuracies in the board’s response to her complaints. We reviewed the correspondence, and found that there appeared to be some confusion around the use of the word ‘ambivalence’, which was used by Ms C’s psychiatrist to describe her approach to her gender reassignment when she was not consistently presenting as female. However, our psychiatric adviser considered these assessments to be appropriate. We also found some inconsistency around the information presented in relation to her attendance at appointments and some confusion caused by a statement from the board’s plastic surgeon. However, we could not find any significant inaccuracies in the board’s correspondence, and did not uphold this complaint.

Recommendations

We recommended that the board:

• ensure that all patients attending/receiving the services of the clinic are, at their first appointment, given verbal and written information of the policies and procedures followed there in relation to gender reassignment surgery; and
• apologise for not referring Ms C for surgery abroad when it would have been appropriate to do so.

Summary

Mr C complained about the care and treatment the board provided after he went to their accident and emergency department (A&E). He said that they failed to appropriately examine and assess his symptoms of severe abdominal pain with urinary and bowel problems. He also said that they inappropriately discharged him at 05:30 in the morning without considering whether he had the means or ability to return safely home. Mr C said that after seeking further medical assistance elsewhere, he was admitted to hospital the next day with an obstructed bowel and was kept in for assessment and treatment.

We took independent advice on this case from one of our medical advisers. The adviser said that the assessment and examination in A&E were of a reasonable standard and that the treatment Mr C received elsewhere the next day did not indicate otherwise, so we did not uphold his complaint about care and treatment. However, the adviser was critical of the board for failing to have adequate discussions with Mr C about treatment for constipation and failing to give him laxatives to take home with him. The adviser also said that they failed to discuss practical arrangements for Mr C's discharge to ensure that he could return home safely. We upheld the complaint about discharge and made recommendations accordingly.

Recommendations

We recommended that the board:

• provide Mr C with a written apology for the failings identified;
• feed back our adviser's comments on the treatment of Mr C's constipation to the staff who examined him in A&E; and
• remind relevant nursing staff of the need to discuss and make appropriate discharge arrangements for patients in A&E and record this information in the clinical notes.
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Summary

Mr C sustained head injuries in a road traffic accident. He went to hospital where his wound was dressed and he was advised to take painkillers. He attended his medical practice the following day for a change of dressing. Several days later he saw another GP who arranged for a nurse to rebandage his wound. He said that it was found to be dirty with glass fragments left in it. Mr C complained about the way his GPs managed his wound. He was also concerned about how one of the GPs managed his subsequent headaches and said he should have been referred for further investigation earlier. Finally, Mr C said that the follow-up by nursing staff, rather than his GP, was not reasonable.

We took independent advice from one of our medical advisers. They said that wound management is a nursing responsibility and that the management and follow-up was appropriate for this type of injury. In relation to the glass fragments, the adviser said these were unlikely to have caused complications and would have worked their way to the surface. It was, therefore, reasonable to allow this to happen and to treat Mr C with antibiotics rather than try to remove fragments, which might have damaged the healing process. In relation to how the practice managed Mr C's headaches, the advice was that further investigations and treatment were provided within a reasonable time, although the GP did not record information about one of the consultations. Having said that, we found that the care and treatment provided overall was of a reasonable standard.

Summary

Mrs C complained that her medical practice failed to diagnose the symptoms of kidney damage after surgery. She said that this meant she had to undergo further surgery and led to a permanent loss of kidney function. Mrs C also complained that after the surgery the practice had failed to take adequate follow-up action.

After taking independent advice from one of our medical advisers, our investigation found that the practice had acted appropriately on the symptoms Mrs C presented with after her first operation. They had monitored her situation and referred her to a specialist when it was clear that she was not recovering. We also found that the practice acted appropriately and in a timely way in trying to support Mrs C, even though they were not advised of Mrs C's discharge, nor about the specialist type of dressing that she had been fitted with. In the circumstances, we found that the practice had provided her with a reasonable level of care.

Summary

Mrs A was diagnosed a number of years ago with early onset dementia. She was admitted to a specialist psychiatric and mental health unit for assessment because of problems with her sleep pattern. During her stay she fell on the ward, breaking her left thigh, and needed a hip replacement in another hospital. Mrs A returned to the unit nine days later and a further 11 days after this fell again, after another patient pushed her. This time she broke her right hip, which also had to be replaced in the other hospital. Mrs A was discharged from there to a nursing home where she is now living. Her daughter (Miss C) complained that Mrs A was provided with inadequate care and supervision while she was being assessed. Miss C also complained that the board's responses to her complaints was inadequate.

We took independent advice from two of our medical advisers. They noted that at times, Mrs A had been on 'constant observations' (where staff were on hand with her at all times) but at other times she was not. The advisers said that Mrs A's mental health condition, falls risk, medication and physical condition were regularly and appropriately monitored and, where necessary, changes were made. Our investigation found that, although it was obviously very unfortunate that Mrs A sustained two fractures within 20 days, her care and supervision were reasonable and appropriate.

On the matter of the complaint responses, our investigation found that all acknowledgements and responses to Miss C's complaint letters were sent within the local and national target timescales. Full explanations were provided and the board acknowledged that this had been a distressing experience for Mrs A and all her family. The board also apologised that in the first response Miss C had not been made aware of the SPSO process. They had not apologised for what happened to Mrs A and Miss C had been concerned about this. We took the view that as we had found that what had happened was not the fault of the board, it was not unreasonable that they did not apologise for this.

Summary

Mrs C complained that a hospital made mistakes in the reporting of an x-ray that her late mother (Mrs A) had taken on 10 April 2012 after falling in her care home and injuring her left knee. Mrs A was discharged from hospital that day but was admitted to a second hospital three days later because she was in severe pain and unable to put weight on her left leg. She was eventually found to have fractured her knee. When the second hospital asked the first hospital to carry out another x-ray seven days after the first, the first hospital found that there had been an error in the reporting of the original x-ray.

Mrs C felt that the board had delayed in taking action to investigate whether there was a problem with the x-ray or arrange a follow-up, when Mrs A's symptoms did not resolve. Mrs C was also concerned that there was a failure to establish the reasons why the x-ray was wrongly interpreted. The board had explained that the likely cause of the error was a problem with their software system for viewing x-rays, which meant that a much older image of Mrs A's knee was superimposed on the new image. They advised that the error was a rare and unusual incident but that they had made relevant staff aware of the matter to ensure it did not happen again. However, our investigation identified that there was also an error with the reporting of the x-ray that was requested seven days after Mrs A fell, as it too was initially noted as showing no fracture. The board said of this that the x-ray image on 10 April 2012 had been displayed when trying to view the image taken seven days later.

We could not say for certain whether the errors in reporting the x-rays were as a result of a failure in the software system, or the wrong x-ray being opened, or if the correct x-ray images were viewed and the fracture was simply not identified. We concluded, however, that the board had not provided sufficient evidence that they had carried out a thorough investigation into both x-ray incidents. However, we noted that the first hospital had promptly arranged for Mrs A to return the following day for a second x-ray after the fracture was identified. We upheld Mrs C's complaints about interpretation of the x-rays, but not about their follow-up action.

Recommendations

We recommended that the board:

• undertake a significant event analysis into the reporting of the x-rays taken after Mrs A's fall, to establish clearly where the fault lay in order to reduce the likelihood of this happening again; and
• apologise to Mrs C for the failings identified.