Health

Summary
Mrs C was a patient of a consultant gynaecologist for about five years, during
which time she had gynaecological surgery, including a hysterectomy. At the
time of this surgery, the consultant noted signs of endometriosis (a condition in
which cells from the lining of the uterus appear outside the uterus). Five years
after the surgery, Mrs C was suffering intermittent pelvic pain and her GP
referred her to the board's gynaecology department.

Mrs C was unhappy with the care and treatment she received after the referral.
In particular, she was unhappy with the information that was provided to her
before surgery to remove her ovary. She felt that information was an
insufficient basis for her to give fully informed consent before surgery. She was
also unhappy about the removal of a stent, and complained that her ureter was
damaged during the ovary surgery. She also said that, due to failures in care
and treatment, she developed preventable infections, including MRSA.

We could not say with certainty what was said to Mrs C in advance of the two
procedures. From looking at the evidence, we found that Mrs C signed consent
forms for each procedure. Both forms stated that the nature and purpose of the
procedures had been explained to her, and that she consented to further
alternative operative measures that might be found necessary during the course
of the operation. In addition, the consent form for the ovary surgery had been
annotated and showed that the potential for bowel and bladder damage were
discussed. We were satisfied from the evidence that consent was properly
obtained and Mrs C was provided with sufficient information, and therefore, we
did not uphold this complaint.

We took advice from three of our medical advisers. One adviser said it was not
possible to say exactly how, or at what stage of, the ovary surgery Mrs C's left
ureter was damaged. The adviser was critical of the sparse record of the
operation and was also of the view, based on the available information, that the
damage to Mrs C's ureter could have been avoided. Given the deficiency in
record-keeping, and taking into account the views of the adviser, we upheld this
complaint.

In terms of Mrs C's treatment in hospital, two of our advisers found no evidence
of failures in care and treatment leading to Mrs C developing preventable
infections. However, based on the medical notes provided by the board, one
adviser was of the view that Mrs C should have been seen by a consultant
gynaecologist more urgently in another hospital, especially when she was still
unwell on the two days following her readmission after ovary surgery. In
addition, the adviser was critical of the wait for a CT urogram (a scan of the
urinary tract) before her move to another hospital. Given these failings in care
and treatment, we upheld this complaint.

Recommendations
We recommended that the board:
• apologise to Mrs C for the damage to her ureter during surgery;
• ensure operation notes include appropriate details, taking account of
Royal College of Obstetrics and Gynaecology guidelines and the
comments made in our decision; and
• draw the failings in care and treatment to the attention of medical staff in
the gynaecology department.

Summary
Mr C's 86-year-old mother (Mrs A) was admitted to The Golden Jubilee National Hospital for hip surgery. Following surgery, she was returned to the ward for bed rest and was noted to be a little confused. The hospital said that they explained to Mrs A that she should not mobilise and to use her call bell if she needed assistance. They said that she seemed to understand this advice.

During the night, Mrs A fell out of bed and dislocated her hip which then required further surgery. Within half an hour, she fell out of bed again and was then placed in an alarmed bed. Since her falls and surgeries, Mrs A’s recovery has been protracted and her long term prognosis is poor.

Mr C complained that his mother was not properly monitored following her surgery. Our investigation confirmed that although Mrs A's first fall could not have been anticipated, the hospital did not take appropriate action after a second fall. We found that the hospital also failed to send Mr C a copy of the appropriate incident report after he requested it.

Recommendation
We recommended that the hospital:
• apologise for failing to send Mr C a copy of the appropriate incident report and that they provide one.
 

Summary
Mr C complained that his practice failed to provide a reasonable standard of medical care on a number of occasions. He went to his practice complaining of pain and was prescribed a drug that he said led to his collapse later in the evening. Later, he went to his practice complaining about severe indigestion and nausea which he believed was a reaction to the medication he was prescribed and was eventually prescribed a different medication. Following an operation, Mr C sought treatment from the practice when he had discomfort and his wound began to leak. He did not receive treatment and went to hospital where he said he was diagnosed with internal bleeding.

We found that on the whole the care and treatment Mr C received from the practice was reasonable. Mr C was prescribed a drug that should have been used with caution, but that there were no contraindications to its use and it was discontinued the following day. We found no evidence that the practice failed to provide a reasonable standard of care to Mr C on the other occasions.

Summary
Mr C's mother (Mrs A) required ankle replacement surgery. Around one week after her surgery, Mrs A was discharged home. Mr C complained that his mother was not properly cared for by the district nursing service to the extent that her ankle became severely infected, and she was disorientated and malnourished. Mr C said that when Mrs A was admitted to Ninewells Hospital around three weeks later, her condition was life-threatening.

Mr C said that the infection in his mother's ankle had also spread to her spine but that despite her pain and the concerns expressed by her family, it took a month to determine and treat the extent of the problem.

We investigated Mr C’s complaint and obtained advice from our medical adviser. The adviser found that the care and treatment given to Mr C's mother was satisfactory and that hospital staff had correctly concentrated on the severity of Mrs A's infection before addressing the pain in her back.

Although Mr C's complaints about his mother's care and treatment were not upheld, we did uphold his complaint about the board's complaints handling. We found that the board took too long to handle and investigate Mr C’s complaint and that they did not comply with their own stated timescales.

Recommendation
We recommended that the board:
• remind all staff involved in this complaint (particularly those who have been asked to respond to the complaints department) of their responsibility to support the NHS complaints procedure by replying in a timely way.

Summary
Mrs C was treated for a vaginal prolapse. She underwent surgery to correct the condition but had complications following the procedure which left her with bladder dysfunction. As a result of this, she required a permanent catheter.

Mrs C was initially taught to intermittently self-catheterise. She was uncomfortable with this procedure and found that it had a detrimental impact on her life. She raised her concerns with the board but it was some time before an alternative form of catheterisation was provided. Mrs C complained that avoidable surgical failures resulted in her losing bladder sensation and that the board failed to warn her in advance that her surgery could permanently damage her bladder. She also felt that the board took too long to investigate alternatives to self-catheterisation.

We found that the board did not warn Mrs C of the possibility of permanent bladder damage prior to her surgery. Whilst we were satisfied that the surgery was carried out correctly and the subsequent complications were unavoidable, we considered that there was an unreasonable delay to providing Mrs C with an alternative to self-catheterisation.

Recommendations
We recommended that the board:
• include information about the potential for permanent bladder problems, and any other significant detrimental outcomes, in their pre-operative counselling for vaginal repair surgery;
• draw their staff's attention to the NICE guidance on surgical repair of vaginal wall prolapse using mesh to ensure that patients are provided with full information regarding the risks and benefits of this procedure prior to giving consent; and
• apologise to Mrs C for the issues highlighted.
 

Summary
An MSP complained on behalf of Mrs A about the Scottish Ambulance Service (SAS). Mrs C's husband (Mr A) suffered a heart attack and the SAS were asked to dispatch an ambulance. The ambulance crew gave Mr A aspirin and carried out an ECG (electrocardiograph). It is normal practice for ECG results to be transmitted to the Golden Jubilee Hospital, which provides specialist emergency treatment for heart attack patients. However, on this occasion, the ambulance crew were unable to transmit the results. The paramedic who attended Mr A phoned the Golden Jubilee for advice, as per the protocol for such situations. He was advised that he could take Mr A to the Golden Jubilee if he was having a heart attack, otherwise he should be redirected to a local Accident and Emergency unit.

The paramedic understood that the correct procedure at that time was to take patients to the Vale of Leven Hospital for initial assessment. He did this, but, upon confirmation that Mr A was having a heart attack, staff at the Vale of Leven redirected him to the Golden Jubilee. By the time Mr A arrived at the Golden Jubilee, another patient had arrived and was treated before him. Mr A did not recover from his heart attack and died three weeks later.

We found that the equipment provided in the ambulance was not properly configured and prevented the ambulance crew from transmitting Mr A's ECG results to the Golden Jubilee. The protocol in place at the time of this incident required ambulance crews to take patients showing signs of a heart attack to the Golden Jubilee in the first instance. We found that the paramedic was not aware of the correct protocol and incorrectly decided to take Mr A to the Vale of Leven, delaying his treatment.

Recommendations
We recommended that the Scottish Ambulance Service:
• apologise to Mrs A and her family for the issues highlighted in this decision notice; and
• consider establishing a standard form of words with PCI (Percutaneous Coronary Intervention) centres to avoid any confusion as to what action ambulance crews are being advised to take.

Summary
Mr C had been experiencing abdominal pain since around 05:00 on a day in June 2010. He became unwell and his pain increased in severity around 22:00. He telephoned the Scottish Ambulance Service (SAS). They did not consider his case to be an emergency and transferred his call to NHS 24. Mr C’s conversation with NHS 24 lasted around 40 minutes, during which time he repeatedly asked for an ambulance to be dispatched to his home. The NHS 24 call handler sought details of his symptoms and ultimately decided to arrange for a duty doctor to call him back within one hour. Mr C was not satisfied with this outcome and arranged for a neighbour to assist him to phone the SAS again. Following this call, a paramedic was dispatched and, following an examination, an ambulance was called. Mr C was found to have a burst appendix.

Mr C complained that NHS 24 should have dispatched an ambulance given the nature of his symptoms. He felt that the number and nature of the questions put to him by the call handler was repetitive, unreasonable and inappropriate. He also complained that it was inappropriate and unreasonable for NHS 24 to suggest that a doctor phone him ‘within an hour’ for further assessment when he was clearly in considerable pain and distress.

We were satisfied with the nature of the questions asked by NHS 24 and found that, whilst there was some duplication, this was kept to a minimum. The evidence that we were presented with showed that there were some communication issues between Mr C and the call-handler and we considered that these contributed to the length of the call more than the NHS 24 call procedure. Our professional medical adviser shared an opinion expressed by NHS 24 that Mr C’s symptoms indicated a need for a physical examination. Mr C had advised the call-handler that he was unable to make his own way to hospital, so we considered it unreasonable for the physical examination to be delayed further by arranging for a doctor to telephone him. We considered that NHS 24 should have made arrangements for a physical examination and, given the symptoms described by Mr C, we found that the most appropriate outcome would have been for an ambulance to be dispatched.

Recommendations
We recommended that NHS 24:
• reflect on their handling of Category C calls and the assessment criteria for transferring cases back to the Scottish Ambulance Service; and
• consider reviewing their criteria for assessing cases of acute abdominal pain to ensure that where rapid escalation of symptoms occurs, this is given due emphasis.
 

Summary
Ms C had a planned operation to remove cysts, uterus, tubes and ovaries. The operation was performed under a general anaesthetic. During surgery, the cysts were not situated as had been thought from the scans and the surgeon decided not to remove these. After the operation Ms C were given morphine for pain relief but she had an adverse reaction to this and further drugs were administered to reverse the effects of the morphine. Following the operation, further scans were arranged to assess the exact position of cysts and a second operation to remove the cysts was carried out five weeks later. This operation was carried out under epidural anaesthetic.

Ms C complained about the timing of her operations and the after care she received in relation to the pain relief prescribed. She also complained that staff failed to remove the clamp from her catheter within a reasonable time causing pain. She also complained that they failed to record medication given which meant that staff attempted to give her analgesia twice.

We found that the timing of the operations were reasonable, as was the anaesthetic provided. However, we found that the board's failures to remove the clamp from Mrs C's catheter within a reasonable time and to record medication given were potentially very serious failures. We did not make any recommendations in light of the action the board had already taken to address the complaint.
 

Summary
Mr C complained that a medical practice acted unreasonably in sending him a letter warning him of unacceptable/intimidating behaviour following a visit to the practice. Mr C disputed that, during the incident in question, his behaviour had been unacceptable/intimidating. In the absence of objective evidence to support Mr C's version of events, we were unable to uphold the complaint. However, we did suggest to the practice that, as a matter of good practice and so that additional evidence is available if they are challenged, they should consider keeping a contemporaneous record of such incidents in future.
 

Summary
Mr C attended his GP with regard to a lesion below his right eye. His GP referred him to a clinic at the hospital for further examination of the lesion. He was reviewed by a registrar initially in November 2010, and attended for the procedure around one month later. When Mr C left the clinic, he found the lesion he was concerned about remained on his face, and a lesion on his nose had been removed instead. Mr C complained to the board.

We found that the notes for the initial clinical appointment contained inaccurate details, and that the lesion for which Mr C’s GP had referred him was not the lesion subsequently identified by the registrar for removal. On this basis, we upheld Mr C’s complaint that the board failed to remove the lesion which he had been concerned about. Mr C had several lesions on his face, and it may also have been helpful if the original GP referral had included details of the other lesions to prevent this confusion arising.

However, we did not uphold Mr C’s second complaint that it was inappropriate to remove the lesion from the side of his nose. Examination of this lesion established that it was a benign tumour and, therefore, it was of clinical concern and certainly the most high risk lesion on Mr C’s face. We also found Mr C had signed a consent form prior to the procedure which stated he consented to any additional procedure which was in his best interests and justifiable for medical reasons.

We did not uphold Mr C’s third complaint that he had been provided with conflicting information regarding the necessity of removing the lesion he had been concerned about. The board had referred Mr C on to a dermatology specialist who had established this lesion was a mole which could be treated satisfactorily with cryotherapy. We did not find this to be conflicting, but in fact appropriate medical advice on the best way in which to proceed.

Recommendation
We recommended that the board:
• apologise Mr C for removing a different lesion on his face to the one he and his GP were concerned about.