Health

Summary

C's spouse (A) became unwell with severe lower abdominal pain and vomiting. C phoned for an ambulance and was told by the Scottish Ambulance Service (SAS) that A's symptoms did not warrant an emergency attendance and transferred the call to NHS 24. A's condition worsened over the next couple of days and A was taken to hospital, where they were found to have a perforated bowel (hole in the bowel) and kidney failure. A was given palliative care and died in hospital shortly afterwards.

C complained about the SAS decision not to dispatch an ambulance to A and considered that the call out system failed to save A's life. We took independent advice from a paramedic. We found that the telephone assessment conducted was reasonable and that appropriate questions were asked. From the responses provided, it was reasonably determined that there were no immediately life threatening symptoms that required dispatch of an emergency ambulance at that time. On this occasion, it was reasonable to transfer the call to NHS 24 for secondary triage to allow a more in depth line of questioning to be carried out to try to understand more about presentation of A's complaint. We, therefore, did not uphold the complaint.

Summary

C complained about the care and treatment that they received from Tayside NHS Board following treatment in the A&E of Ninewells Hospital. C attended the A&E after sustaining an injury to the little finger of their right hand caused by a serrated knife. They were diagnosed and treated for mallet finger (a deformity of the finger when the tendon that straightens the finger is damaged at the fingertip), of which treatment involved the application of a splint to the injured finger.

C complained to the board that their injury had failed to heal correctly. C complained that they were not given an x-ray, that the splint was too big and that they were given insufficient information to allow them to care for their injury. C also complained that they had not been provided with a face-to-face physiotherapy appointment timeously.

We took independent advice from an emergency medicine adviser. We found that C's injury was wrongly diagnosed and that, consequently, the application of a splint in C's case was not the appropriate treatment. We found that the A&E should have referred C to a hand surgeon. We upheld this aspect of C's complaint.

We found that it was the responsibility of C's GP practice to arrange a timeous referral to physiotherapy. We, therefore, did not uphold this aspect of C's 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 attending the A&E with this type of injury should receive appropriate diagnosis and treatment.
• The board have said that they will ensure C's feedback was used within the A&E to ensure that any ill-fit of splints is explained fully in future as part of the aftercare advice.

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 the board failed to fully consider an allergic reaction to a wasp sting as the cause for their blackout which occurred when driving a HGV (heavy goods vehicle). When C was taken to hospital following the incident, a tryptase test was taken (a test to diagnose anaphylaxis, an acute allergic reaction). An ECG (a test to check the heart's rhythm) showed that C had an irregular and fast heartbeat and an EEG (a recording of brain activity) showed abnormal results with potential epileptic activity. Due to these findings, C was instructed not to drive and the DVLA were informed.

We reviewed the medical records and took independent advice from an acute medicine adviser. We found that while it was reasonable for the board to arrange for further investigations given that there were a number of potential causes for C's blackout, it would have been reasonable to further investigate an anaphylactic cause for the collapse once the tryptase result was available. Instead, C decided to seek private specialist opinion and the board only referred C to an allergy specialist after a significant amount of time and correspondence from C. We therefore upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to fully consider an allergic reaction as the cause for C's blackout. 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:

• Potential causes of blackouts/collapses should be fully 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 the care and treatment that their sibling (A) received from the board was unreasonable. A had previously been diagnosed with breast cancer and had a mastectomy (surgical removal of the breast tissue). When A became ill, the symptoms were considered to be related to irritable bowel syndrome (IBS, a condition of the digestive system that can cause stomach cramps, bloating, diarrhoea and constipation). A's symptoms persisted and A was admitted to hospital on numerous occasions. A scan showed a tumour attached to their kidney and they died some months later.

C complained that despite A's multiple hospital admissions and concerns that the cancer had returned, the board failed to reasonably respond to A's worsening condition and delayed or failed in carrying out appropriate investigations.

We took independent advice from a consultant colorectal and general surgeon adviser. We found that, overall, there was a failure to adequately investigate symptoms, take into account patient history, and appropriately manage A's care, including acting on findings of sclerotic bone lesions (an unusual hardening or thickening of your bone) and a failure to consider an overarching diagnosis. Whilst the board did carry out a Significant Adverse Event Review (SAER) in relation to A's care and treatment, this failed to identify all of the failings highlighted above. As such, we upheld C's 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 investigations, including radiological investigations, should be considered for patients presenting with abdominal pain, recurrent vomiting and diarrhoea not known to be infective and with no explanation.
• CT KUB findings (scan of the kidneys, ureters and bladder) of sclerotic bone lesion should be investigated appropriately.
• When SAERs are carried out, failings should be identified appropriately and action should be taken to ensure that lessons are learned.

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, who suffered with hip problems, was diagnosed with a labrum tear (a condition which occurs due to damage of the soft cartilage that rims the socket portion of the hip joint) and underwent surgery.

C's symptoms failed to resolve following surgery and they were informed during a follow-up consultation that a metal artefact was visible on x-rays of their hip. C complained to the board about the advice to proceed with surgery and the treatment that they received.

C also complained about their concerns regarding their assessment and suitability for surgery to address their symptoms, and that the surgery had been carried out unreasonably.

We took independent advice from an orthopaedic (conditions involving the musculoskeletal system) adviser. With respect to C's complaint about diagnosis and treatment which resulted in the hip surgery being undertaken, we found that C underwent appropriate assessment. We found that the surgery, including relevant complications, was discussed and C had consented to the procedure. On this basis we did not uphold this aspect of the complaint.

With respect to the complaint that the board failed to provide appropriate care and treatment during, and following, the hip surgery, we found that whilst the surgery was performed to a reasonable standard, and subsequent problems investigated reasonably by clinicians, the board failed to comply with the duty of candour when they failed to inform C after the operation about the failure of a metal anchor used in the hip repair. We also identified that the board, in their complaints investigation and response to C, failed to adequately address the issue of the metal artefact in their hip following the operation. We therefore upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to meet its duty of candour. 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:

• Discussion by the Orthopaedic Department Clinical Governance meeting of the requirements around Duty of Candour, including reflection on C's case.

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 underwent a hysterectomy (surgery to remove the womb) and although the procedure was considered successful, C began to bleed from scar tissue soon after the operation. An ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) showed blood clots in C's pelvis and C was kept in hospital in case further surgery was required. C was given blood thickeners and a blood transfusion. C developed a chest infection and suffered from further complications.

C raised complaints about their care and treatment following their initial surgery with Greater Glasgow and Clyde NHS Board. C raised a number of specific concerns about their post-operative complications and their management. C was also concerned about the surgery, or that the post-operative complications had caused the nodule on their lung, which was subsequently identified as lung cancer.

We took independent advice from a gynaecology (medicine of the female genital tract and its disorders) adviser. We found that C's care and treatment was reasonable and that C had experienced significant post-operative complications, but that these were appropriately managed. We noted that there was no evidence that C received inadequate consultant input post-surgery, or that C's complications were as a result of the surgery being performed poorly or inappropriately. We found that the board were correct to say that there was no relation between C's surgery and the subsequent health issues that they faced. We also found no fault with the level of physiotherapy support offered to C.

We concluded that C's medical records showed that they were regularly reviewed by a physiotherapist and that the exercises that were provided to C were also reasonable and appropriate. As such, we did not uphold C's complaint.

Summary

C complained about the care and treatment that they received from Greater Glasgow and Clyde NHS Board. C was referred to the Early Pregnancy Unit (EPAS) by a private clinic on two occasions. C complained that EPAS took too long to declare the pregnancy non-continuing, that C was required to attend an unnecessary number of scans and that their care was not escalated to a doctor. C also complained that the advice and care that they received by phone, and the fact that they were contacted and invited to a reassurance scan, was unreasonable. C further complained that EPAS asked them for distressing information rather than gathering this from the private clinic and that EPAS did not gather consent from C for surgical management as they ought to have done. C also complained that the care and treatment that they received as an inpatient was unreasonable.

The board noted that they apologised for the delay in the time C waited to be seen, that during their admission C fainted and was lowered to the floor by a nurse who then called a doctor, that all options were not discussed and that on reflection there was a missed opportunity to obtain a second opinion. The board also noted, however, that this would not have changed C's management plan.

We took independent advice from a consultant obstetrician (the medical specialism for pregnancy, child birth etc) and gynaecologist (medicine of the female genital tract and its disorders). We found that a second opinion should have been sought, which may have allowed miscarriage to be diagnosed earlier. We also found that C should not have had to relay findings or be subjected to repeated examination when diagnosis had already been made by the private clinic and that the necessary documentation ought to have been obtained from the private clinic. We further found that during C's fainting episode, appropriate observations and actions were taken and the faint was well managed.

In light of the above, we found that whilst it was reasonable for EPAS to repeat some scans, a second opinion was not sought when it should have been. If this happened, C's miscarriage could have been diagnosed earlier, and therefore, the care and treatment provided to C was unreasonable. Additionally, the actions of EPAS asking C to relay findings and requiring C to undergo a further scan was unreasonable. We found that C's faint was well managed and the care and treatment provided to C during this time was reasonable.

We also considered the way in which the board handled C's complaint. We found that it does not appear that the board's complaint investigation took account of the clinical notes made by the doctor to ensure a full and accurate response was provided.

We partially upheld C's complaint and made recommendations to the board as a result.

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/informationleaflets.

What we said should change to put things right in future:

• Patients attending EPAS should not be required to undergo unnecessary scans.

In relation to complaints handling, we recommended:

• When carrying out an investigation, consideration should be given to ensuring the response takes into account any relevant clinical notes so that the complainant receives a full and accurate response.

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 late parent (A) by Dr Gray's Hospital. C complained that A's colorectal symptoms and weight loss were not properly investigated and that a planned scope investigation wasn't arranged on an urgent basis. C also complained that a head injury A sustained in a fall was not properly investigated and that A was inappropriately discharged when they were unfit to return into C's care. A was re-admitted the following day and died in hospital around two and a half weeks later. C complained about the standard of medical treatment provided during this admission. Furthermore, C complained about the nursing care provided during A's final admission. They complained that visits did not take place in an appropriate location to ensure A's comfort and privacy, and in particular that A was not transferred to a side room in light of their condition. C also considered that A was denied adequate nutrition and hydration. Finally, C complained of difficulties obtaining information from the ward and more generally about communication with the family and the lack of visiting opportunities that they were afforded.

We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly). We found that there was no evidence to indicate the need for urgent investigation. We did not uphold this aspect of the complaint.

We found that A's care surrounding the head injury was reasonable and that they did not meet the criteria for a head scan. However, we noted that there was a lack of care and attention to A's confusion and falls risk and that they should have been kept in hospital. On balance, we upheld this aspect of the complaint.

We noted that A received an appropriate medical review and treatment, apart from a delay in initially being reviewed by a consultant and a lack of attention to A's deterioration prior to their death. We also noted a failure to communicate the DNACPR process to C, but noted that the board had acknowledged this and outlined appropriate steps to address it. Taking communication and the lack of consultation together, in careful and close balance, we upheld these aspects of complaint.

In relation to C's complaint about the nursing care provided during A's final admission, we took independent advise from a nursing adviser. Other than an identified omission where nursing staff failed to sign for prescribed dietary supplements, which the board acknowledged, we found that A received a reasonable standard of nursing care. Therefore, on balance, we did not uphold this aspect of the complaint.

In relation to communication, the board acknowledged that the family weren't afforded the opportunities that they should have been following a change in guidance. We asked the board to provide evidence of the steps that they were taking to ensure staff are kept updated on changes to visiting guidance. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the lack of care and attention to A's level of confusion and the unreasonable decision to discharge them, for the lack of consultant review after A's later admission, for the failure to communicate the DNACPR process to C and for the lack of recognition of A's deterioration and failure to inform C of this. 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 findings of this investigation should be fed back to relevant staff for reflection and learning including, staff reflection on the decision making surrounding A's discharge, the level of consultant input in the days following their readmission and the care and attention given to A's deterioration and lack of communication with C. The consultants concerned should include the findings of this investigation as part of their annual appraisal process.

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 by the board to their late spouse (A) who was diagnosed with muscle-invasive bladder cancer. C complained about various aspects of the care that A received. These included delay, and ultimate failure, to carry out surgery to remove A's bladder, inappropriately high and missed doses of medication, and initial refusal to offer chemotherapy (a treatment where medicine is used to kill cancerous cells). C also complained about a failure by an out of hours doctor in identifying a deep vein thrombosis (DVT, a blood clot in a vein) that A developed and subsequent provision of insufficient information on medication used to treat the DVT. C further complained about various failures of communication as well as concerns about arrangements for visiting A due to the Covid-19 pandemic and end of life care.

We took independent advice from medical advisers with expertise in oncology (cancer specialist), urology (a specialty in medicine that deals with problems of the urinary system), general practice and community nursing. We found that A's pain medication regimen was reasonable and that the timescale for the scheduling of A's bladder removal surgery had been appropriate. We also found that decisions made about the timing of chemotherapy and communication with A had been reasonable. This included communication about A's end of life care and how rules relating to visiting A during the pandemic had been applied.

However, a number of failings in the treatment provided to A were also identified. We found that A had not been given appropriate information on the extent of their cancer, the prognosis and the potential treatment options. We also found that there had been an unreasonable delay in the discussing of A's case by the board's multi-disciplinary team, which also understated the extent of A's cancer. Furthermore, we found that A missed doses of regular medication when attending for palliative chemotherapy, that the DVT A developed was unreasonably not initially identified and, once diagnosed, insufficient information was given to A about medication given to treat the DVT.

For these reasons, we upheld this 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 diagnosed with DVT should be given appropriate information on anticoagulants (drugs that reduce the body's ability to form clots in the blood), in line with relevant clinical guidance.
• Patients should be given a comprehensive assessment of their end of life care needs, including support for sleeping, which is then clearly recorded in their nursing records.
• Patients should be given timely, clear and accurate information about the extent of their cancer, prognosis and management options. Patients should also receive appropriate support from clinical nurse specialists, in line with relevant clinical guidance.
• Patients requiring urgent care should be referred to specialists within a reasonable timeframe.
• Patients should be appropriately referred to the multidisciplinary team within a reasonable timeframe.

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 late child (A) by their GP practice. A had attended the practice on several occasions over a five month period with persisting chest symptoms. C complained that the practice failed to recognise the severity of A's symptoms or recognise that symptoms were indicative of a serious cardiac condition until A's health had significantly deteriorated. A subsequently suffered a cardiac arrest resulting in them being transferred to another health board for surgery, where they later died.

We took independent advice from a GP adviser. Although we noted that there had been a delay of a few days in responding to A's x-ray report, we found that the practice's care of A was reasonable, with referrals and tests being timeously arranged and in keeping with A's presenting symptoms at the time. Therefore, we did not uphold the complaint.