Health

Summary

C complained about the care and treatment that they received from the board for their right sided hearing loss. They complained that they had been misdiagnosed and wrongly advised that a hearing aid would improve their situation, and that no surgery would help them. C later accepted a second opinion and was referred to a hospital outwith the board area where they received a different diagnosis and treatment (a bone anchored hearing aid) which they said improved their quality of life.

We took independent advice from an ear, nose and throat consultant. We found that C’s audiogram (hearing test results graph) had been unreasonably misinterpreted and C was misdiagnosed. We found that the treatment that was given (a standard hearing aid) was not suitable for C’s actual condition. We found that C should have been offered a Crosaid (a device worn behind the ear which routes sound from the affected ear to the unaffected ear), or the surgical option (a bone anchored hearing aid) which was eventually provided when C obtained a second opinion.

We also considered that C was not provided with reasonable advice regarding the use of a hearing aid, that there was a failure to take a careful history for C and pick up on the clues in the referral letter from C’s GP as to the nature of the onset of C’s hearing loss, and a failure to arrange appropriate investigations for C. We also found that there had been failures in the way in which the board had communicated with C about their hearing loss, and we were critical of the way the board investigated and responded to C’s complaint. We therefore upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for unreasonably advising them that they had otosclerosis (a disorder, sometimes hereditary, in which there is formation of new bone around the base of the bone of the middle ear, resulting in progressive hearing loss), when they had sensorineural hearing loss (resulting from damaged hair cells in the inner ear), failing to provide C with appropriate treatment for their hearing condition and failing to provide appropriate advice on the use of hearing aids. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informan-leaflets.

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

• For the board to appropriately interpret scan results, make appropriate diagnoses in cases such as this, take into account all relevant information, including patient history/GP referral information and test results, identify and arrange appropriate investigations and provide appropriate treatment and advice on the use of hearing aid devices.

In relation to complaints handling, we recommended:

• The board's complaint handling monitoring and governance system should ensure that concerns raised are appropriately investigated, failings (and good practice) are identified and that learning from complaints is used to drive service development and improvement. There should be a review of complaints by senior staff during the board’s investigative 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 follow-up care provided to their late partner (A) who died around four months after suffering a heart attack. The board said that A was followed up by the cardiac rehabilitation service in line with established practice. We took independent advice from a consultant cardiologist (a specialist in diseases and abnormalities of the heart). We found that A's follow-up care was reasonable in the circumstances (of no face-to-face consultations due to the COVID-19 pandemic). We also found that it was reasonable for the board not to follow up on blood tests taken at A&E following A's attendance with chest pain. The board said that the test results showed no evidence of a new cardiac injury. We considered it reasonable to have excluded a new cardiac injury as the cause of A's chest pain, and we were not critical of the care provided. Therefore, we did not uphold these aspects of C's complaint.

C also complained about the conduct of a telephone consultation with a cardiac rehabilitation nurse. A called to report symptoms of breathlessness and C complained that the nurse diagnosed a chest infection and/or anxiety over the phone, and did not arrange for A to be seen. However, the nurse did not recall making such a diagnosis, and their recollection was that there was no apparent indication for A to be seen. We were unable to reconcile the differing recollections, and we considered that the actions of the nurse appear to have been consistent with reasonable practice. C was unhappy that the call was not documented. The board said that the call was not documented as A had been discharged from the cardiac nurse service, and in such circumstances patients are directed to their GP for any advice required. We noted that referral back to primary care for non-urgent symptoms is consistent with established good practice. We did not uphold this complaint.

Finally, C complained that A's post mortem described A as having severe heart disease, and they complained that they had been advised everything was fine following A's heart attack and stent insertion. We found that comparison between findings pre and post death, four months apart, is problematic and can be complicated by a number of factors. We noted that the disease seen at post mortem may not have been present four months earlier and we considered A's care was reasonable based on what was known at the time. We did not uphold this complaint.

Summary

C complained about the care and treatment that their late parent (A) received at University Hospital Monklands. A was admitted to hospital to have fluid drained from their abdomen but died in the hospital a few days later. C was concerned that the drain was left in too long and caused A to suffer a perforation of the bowel, and that medical staff delayed and/or failed to investigate whether A had suffered internal damage as a result.

We took independent advice from a consultant hepatologist and gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the gastrointestinal tract, liver, pancreas and gall bladder). We found that without a post mortem it was impossible to determine the cause of the perforation. We also found that while A's drain had been left in longer than recommended, it was unlikely that the delayed length of time the drain was left in and the subsequent perforation were related, as A did not have any immediate complications nor signs of problems from the drain for a number of days before developing a bowel perforation.

We found that the clinical action taken by the team involved in A's care at this time was reasonable. Once there was a suspicion of a perforation occurring, a chest x-ray had been carried out and this had been good practice. The board acknowledged and identified lessons to be learned and we considered the board's actions to address what occurred were reasonable. However, we found that the delay in removing the drain was unreasonable and we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable delay in removing A's drain. 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:

• There should be good communication between the medical team (inserting the drain) and the nursing team with regards to the timing and the removal of a patient's drain.

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 and B complained about the board's handling of reports of alleged elder abuse in relation to a family member (A). They also complained that the board had failed to handle appropriately a referral made to the District Care Panel (DCP) for residential care for A, and had failed to give sufficient consideration to A's circumstances and that they were at risk of harm when rejecting the request. They also complained that following concerns for A's welfare, A had been removed from their place of residence, but the board had failed to properly assess A's care needs or to provide A with a reasonable level of support. In pursuing these matters, C and B said that the board's communication with them had fallen below a reasonable standard.

We took independent advice from a social worker. We found that although the Adult Support and Protection (ASP) investigation was procedurally sound, it had been lacking in quality. The board's analysis of A's circumstances and the Personal Outcome Plans were lacking, and were not persuasive in assessing a care need. As such, we found that the board had failed to safeguard A. We upheld this aspect of the complaint.

We also found that although the DCP handled A's referral for residential care appropriately, the information provided to the DCP was lacking in terms of the quality of the ASP investigation and the robustness of the case presented regarding A's situation. As such there was a failure by the board to prioritise securing urgent short-term accommodation that took account of A's circumstances. We upheld this aspect of the complaint.

We found that following A's removal from their place of residency, the board had followed up with A reasonably. We did not identify any further shortcomings in the board's assessments of A's care or living needs. We did not uphold this aspect of the complaint.

Finally, we found that the board had, at times, failed to respond to C and B's questions and requests for information regarding their concerns about A. We also found that there had been occasions where the board's correspondence with C and B had been unreasonably slow. We therefore upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and B for the poor handling of their correspondence. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C, B and A for the issues 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 (i) share this decision notice with the staff involved in A's case with a view to reflecting on how the ASP investigation could have better identified the nature and extent of their situation and pushed for an outcome that would have better protected A; and (ii) use this case as a reflective exercise to consider the effect of undue pressure and trauma on decision-making in ASP cases.
• The board should review how they track and respond to general correspondence to ensure all points are responded to fully and within a reasonable timescale.

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 and their child (A) received from the board. Over the course of nine months, C and A attended a number of appointments with the board's Child and Adolescent Mental Health Service (CAMHS) in respect of difficulties A was experiencing. C complained about the content and nature of these sessions. In their view, the board failed to progress a neurodevelopmental assessment of A within a reasonable timescale, which C considered was one of the key reasons for the referral. C also felt inappropriate assertions were made about them and their parenting skills. In C's view, they were unreasonably picked on during sessions with CAMHS. As a result of this, C's view is that CAMHS failed A and did not provide them with reasonable care and treatment.

C also complained about a child concern referral that was made by the CAMHS service. C considered this to be inappropriate and that it was done in response to them raising concerns about the actions of CAMHS.

We took independent advice from two advisers: a mental health nursing specialist and a clinical psychologist, both with a background in CAMHS. We found that the care and treatment provided by CAMHS was reasonable in the circumstances. Given the content of the referrals from A's GP and social worker, CAMHS embarked on an appropriate course of treatment and therapy. While we recognised that this did not result in a positive outcome for C or A, we did not consider the board's actions to be unreasonable. Therefore, we did not uphold C's complaints about the care and treatment provided by CAMHS.

Summary

Following the extraction of a wisdom tooth in hospital, C's follow-up care was undertaken by their family health service dentist. C suffered altered sensation following the tooth extraction. Over the course of eight months, C arranged three consultations with their dentist at which the altered sensation was discussed. C was concerned that the dentist's actions had not addressed the altered sensation and raised complaints about this with them and, subsequently, with this office.

We took independent advice from a dentist. We found that the dentist provided reasonable care to C and did not uphold the complaint.

When this report was first published on 21 September 2022, it was incorrectly categorised as being about a medical practice. This was due to an administrative error which we discovered on 20 October 2022, and for which we apologise.

Summary

C, an MSP, complained on behalf of their constituent (A). A had suffered severe pain in the years following a porcine mesh implant (a surgical device, consisting of mesh made of animal tissue, such as intestine or skin, that has been processed and disinfected to be suitable for use implanted into a patient to strengthen a surgical repair) to rebuild their abdominal wall. For a number of years, a pursued treatment for the pain with the board and the possibility of the removal of the porcine mesh. The board's gynaecology department (specialists in the female reproductive system) ultimately advised that they were unaware of any relationship between porcine mesh implants and chronic pain. A was referred to plastic surgery but this was declined on the basis that the plastic surgery department had no additional treatments to offer A.

C asked the board for an independent review of A's case and an assessment for surgery to remove the porcine mesh. The board told C that the gynaecology and plastic surgery departments would review A's case in collaboration. A was ultimately only offered an appointment with gynaecology. Following further consideration, but without a joint appointment for A with the two departments, the board concluded that A was being offered appropriate treatment options and that removal of the porcine mesh would not relieve A's pain. The board advised A to seek a joint gynaecology and plastic surgery referral via their GP.

We took independent advice from a consultant plastic surgeon. While we found that the assessment of A's pain by the board had been reasonable, we concluded that this had not been reasonably explained to A in a single, clear and comprehensive communication that addressed all of the concerns and queries A raised regarding the nature of the mesh used, why this was distinct from the mesh referred to in media reports, why this was unlikely to be contributing significantly to A's pain and why there was no surgical procedure available to remove it. We concluded that it was unreasonable to have promised a joint consultation between gynaecology and plastic surgery and then not carry this out, despite acknowledging that A sought this and having several opportunities to arrange the joint consultation. Given this, we upheld C's complaint that the board had not reasonably assessed or explained the source of A's pain.

However, we concluded that the board's treatment plan for A's pain was reasonable. While the board's decisions on treatment and reasons for these were not well communicated to A, the board reasonably investigated A's condition and reached a reasonable position regarding treatment. Given this, we did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A that they unreasonably failed to arrange a joint appointment with the plastic surgery and gynaecology departments, and to explain their conclusions regarding A's pain in a reasonable way. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Arrange and undertake a joint appointment for A with the plastic surgery and gynaecology departments.

In relation to complaints handling, we recommended:

• Staff should handle complaints in line with the Model Complaints Handling Procedure, which includes addressing all the areas the board are responsible for and explaining the reasons for their decisions.

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'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.