Health

Summary

C complained on behalf of their child (A). A attended their GP practice and A&E at University Hospital Hairmyres on a number of occasions before examination by a physiotherapist led to a referral back to hospital, further x-ray and diagnosis of slipped upper femoral epiphysis of the hip (SUFE, where the growing part of the bone in the hip joint moves). C complained that A was advised to continue walking unaided despite being in severe pain. C believes failings in care contributed to A’s condition worsening to the point where significant surgery was required. C was dissatisfied with the board’s response to their complaint and asked this office to investigate.

In their response to our enquiry, the board confirmed that A’s case had been discussed at a Morbidity and Mortality review, with learning identified. They said that the initial referral letter from the GP to orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system) prompted no red flags from the orthopaedic team and they suggested musculoskeletal physiotherapy in the first instance. A was given an appointment but they attended A&E in the interim.

We took independent clinical advice from a consultant in emergency medicine and a consultant orthopaedic surgeon. We found that SUFE was a difficult condition to diagnose and we did not consider the delay in diagnosis to be unreasonable. We were, however, critical of the decision to discharge A without further investigation, when they were unable to weight-bear. We noted that the board had identified learning but considered they also ought to develop a multidisciplinary pathway for the limping child. We also found that the referral from the GP was assessed appropriately in view of the information it contained. On balance, we did not uphold this complaint but provided the board with feedback in relation to the issues mentioned above.

Summary

C complained about the standard of medical care and treatment provided to their parent (A). A received a likely diagnosis of metastatic lung and liver cancer. They were placed on palliative care, however, after approximately a year, A remained in good health. C sought a further review, A received subsequent scans, and it was ultimately established that they did not have cancer (approximately two years after the original diagnosis).

C raised concerns about the basis for the initial diagnosis that A had cancer. They also complained about the subsequent management of A. C said there was no appropriate follow-up or subsequent communication after the diagnosis. Ultimately, C requested a review, but said it took significant time for the board to establish there was no cancer.

We took independent advice from a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) and a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the diagnosis that A likely had cancer was reasonable. It was based on a reasonable radiological opinion given the findings on A’s CT scan. We did not uphold C’s complaint in that regard.

In relation to A’s subsequent management, we found that there were unreasonable failings. The standard of care and attention the board provided to A following discharge was not reasonable, and we found evidence that follow-up was proposed for A and then not acted on. We also found that there was a failure to respond within a reasonable time to the referral for an oncology review. We upheld this aspect of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the failings identified in this investigation and include recognition of the impact the failings have had on them. The apology should meet the standards set out in the SPSO guidelines on apology at www.spso.org.uk/information-leaflets.

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

• Ensure effective systems are in place for review on hospital discharge and communication is effective especially where there is diagnostic uncertainty.

In relation to complaints handling, we recommended:

• Ensure board investigations identify and address incidents covered by the Duty of Candour with the relevant Scottish Government guidance.

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 their late parent (A) received at Queen Elizabeth University Hospital. A was admitted to hospital with a diagnosis of pancreatitis (inflammation of the pancreas). They were treated with fluids and antibiotics and their fluid balance was measured. They recovered and were discharged later that month. A was readmitted with various symptoms including abdominal pain, vomiting, loose stools and not eating or drinking on two further occasions and was discharged both times. A was later readmitted to the hospital in cardiac arrest and died shortly after arrival at the hospital.

We took independent advice from an appropriately qualified adviser. We found that the board failed to provide A with a reasonable standard of care and treatment. During one admission, there was a lack of comment on A’s hernia, a lack of investigation of low blood pressure and no evidence of a cardiology (specialists in diseases and abnormalities of the heart) input. On another admission, we found that the care and the management plan concerning A’s hernia was below standard and that there appeared to be a delay in the involvement of other specialists. We also found issues relating to the planning of surgery for A. Therefore, we upheld this aspect of C's complaint.

C also complained that A's final discharge from hospital was unreasonable. We found A's discharge to be reasonable and did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not making a timely assessment of risk for surgery, the failure to address A’s low blood pressure, the standard of monitoring and examination of A’s hernia, the delay in the involvement of clinical specialists, the standard of the management plan for A's hernia repair, the standard of planning of A's urgent surgery and for delays in surgery. 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 have a policy in place on the management of emergency cases and prioritisation to ensure delays and recurrent cancellations of cases are minimised.
• The board should review how deteriorating patients are managed to ensure timely involvement of relevant specialties in care when there are complex patients.
• Ward round documentation needs to reflect concerns and management plans clearly.

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 was suffering from swelling and pain in their right knee. C attended an appointment with a consultant vascular surgeon (a specialist in the treatment of diseases affecting the vascular system including diseases of the arteries, veins and lymphatic vessels). The consultant noted that C had varicose veins (swollen and enlarged veins that usually occur on the legs and feet) but believed them to be uncomplicated. The consultant felt the swelling in the right leg was not caused by a problem with the veins and that there were no other symptoms of venous disease. C was not referred for vascular surgery. C had an ultrasound scan which confirmed the lump on the leg and the symptoms were likely caused by a trapped nerve.

C complained that the care and treatment provided were not reasonable and that it was unreasonable not to refer them for varicose vein surgery.

We took independent advice from a consultant adviser. We found that the examination and conclusions of the board were reasonable on the basis of C’s condition at the time. We noted that there were no indications that further vascular investigations/treatments needed to be offered. Additionally, we were satisfied the board had appropriately applied the National Policy NHS Protocol for access to Varicose Vein surgery.

We did not uphold the complaints.

Summary

C complained in relation to their late sibling (A) who was admitted to Glasgow Royal Infirmary following a fall. During their time in hospital, they contracted various infections (latterly pneumonia) and was diagnosed with dementia. A's health deteriorated during their time in hospital and they died.

C said that medical staff failed to take adequate steps to ensure that A received sufficient nutrients to fight the infections they acquired whilst in hospital and this was a contributory factor in their death.

We took independent advice from an appropriately qualified adviser on the care and treatment, specifically the feeding aspect, and found that the care and treatment provided to A was reasonable. We did not uphold the complaint.

Summary

C complained that the board unreasonably carried out a biopsy after a mass was identified in C’s chest. C said due to the type of tumour it shouldn’t have been biopsied.

We took independent advice from a consultant physician and rheumatologist (a specialist in rheumatism, arthritis, and other disorders of the joints, muscles, and ligaments) and a consultant radiologist (a specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans).

We found that while the type of tumour should not have been biopsied, it was not identified as that type of tumour until after the biopsy and that was reasonable. We found that the decision to perform a biopsy was reasonable based on the information available at the time. As such, we did not uphold this complaint.

Summary

C complained about the care and treatment provided to one of their twins (A) at delivery and in the neonatal unit after delivery at Queen Elizabeth University Hospital. C was concerned, in particular, about blood loss at birth, the delay in a blood transfusion being carried out, a delay in blood pressure being taken, record-keeping and communication.

We took independent advice from a consultant obstetrician (a doctor who specialises in pregnancy and childbirth) and a consultant neonatologist (a doctor who specialises in the medical care of newborn infants, especially ill or premature newborns).

We found generally that the evidence in the records showed a safe and appropriate delivery. We found that the blood loss at birth was within the standard parameters for twins delivered by caesarean section, although it is accepted that it was not possible to establish the total blood loss for A. We also found a blood transfusion was carried out within an appropriate timescale. However, A did not have their blood pressure taken until three hours after being admitted to the neonatal unit. We found it would be standard practice for a ventilated and unstable baby on a neonatal unit to take a non-invasive blood pressure reading. The board did not have a policy requiring this. Therefore, we upheld this complaint.

In addition the board accepted their record-keeping during delivery was not of an appropriate standard. They also recognised that communication required to be improved, and they have taken steps to address both of these issues. We identified concerns about record-keeping in the neonatal unit and this has been brought to the board’s attention.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for the failings this investigation has identified. The apology should meet the standards set out in the SPSO guidelines on apologyavailable at www.spso.org.uk/information-leaflets.

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 parent (A) had a history of heart problems and suffered a cardiac arrest. Investigations at that time led to a diagnosis of deep vein thrombosis (DVT, a blood clot in a vein). Four years later, A’s heart condition had deteriorated and they were assessed for a possible heart transplant. These investigations indicated severe pulmonary oedema (a condition caused by excess fluid in the lungs) and significant emphysematous changes (emphysema is a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness) which meant A was not a suitable candidate for a transplant. The presence of emphysema was previously unknown to A. A died the following year due to heart failure with emphysema listed as a secondary cause. The doctor completing A’s death certificate found mention of mild emphysematous changes in the discharge letter around the time of the diagnosis of DVT. This was the first time A’s family had been made aware of these early findings.

C complained about A’s care and treatment. The board responded that mild emphysema is a very common incidental finding in CT scans of patients, such as A, who are cigarette smokers. The board said the degree of emphysema found was mild and would not have contributed to A’s symptoms or altered the plan for investigation at the time or the care provided to A subsequently. The board gave their view that there was no treatment that could have been offered that would have prevented the progression of the emphysema. The board apologised that they did not provide more information to A about the results of the CT scan at the time and advised that the case had been shared with the cardiology team and the importance of scan results being discussed with patients and recorded in their notes had been reinforced. C was unhappy with this response and brought their complaint to this office.

We took independent medical advice from a consultant in respiratory and general medicine. We found that, although the discharge letter included mention of mild emphysematous changes, emphysema was not included in A’s list of diagnoses and this meant that the board did not reasonably record the findings of the scan in A’s medical records and that a formal diagnosis of emphysema should have been recorded. We also found that A was not reasonably informed of the finding of emphysema or given any of the information recommended in the relevant guidance beyond general smoking cessation advice. While we also noted that stopping smoking was the only effective treatment available for emphysema, what cannot be known is whether a formal diagnosis of emphysema would have had any effect on A’s ability to stop smoking.

We also found that a reduced gas transfer result should have been followed up with a CT scan of A’s lungs. However, this would not have changed A’s treatment or overall outcome.

Overall, despite the board’s failures, C received treatment compliant with relevant guidance and these failures did not materially impact the subsequent progression of the disease or A’s eligibility for a heart transplant. On balance, however, we upheld the complaint that the board’s treatment of A unreasonably failed to take into account the finding of mild emphysematous changes in A’s early scan.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for the specific failings identified. The apology should make clear mention of each of the failings identified and 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:

• Relevant board staff are aware of the relevant guidance in respect of incidental findings of emphysema on CT scans and of the need to follow up significantly reduced gas transfer results with a CT scan of the lungs.

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 practice refused to provide their late parent (A) with an in-person GP appointment. A had a history of lung cancer which had been treated with radiotherapy (a treatment of disease, especially cancer, using high-energy radiation) previously. A contacted the practice by phone to report pain in their right leg and buttock. A was not seen in-person due to COVID-19 guidance, however a telephone consultation was arranged. The consulting GP considered that A’s symptoms likely resulted from sciatica (back and leg pain caused by irritation or compression of the sciatic nerve) and prescribed treatment for this. Further phone consultations followed with the GP and others at the practice on four other occasions. The consultations consisted of a mixture of planned contacts by the GP and unplanned contacts by A. C later contacted the practice and expressed concern that A’s condition had not improved. C asked for A to be seen in person. A was seen by a GP that day. A’s case was discussed with an oncology (cancer) nurse specialist. It was agreed that A’s condition required further investigation. A was subsequently referred to an oncology clinic and was diagnosed with metastatic lung cancer. A died the following year.

We took independent advice from a GP. We found insufficient evidence to suggest that the practice had refused any request from A for an in-person appointment. However, we did find that there had been a unreasonable delay in providing A with an in-person appointment. On consideration of relevant guidance, the clinical record and specialist advice we found that A should have been seen in-person on the third contact they had with the practice. We considered that the delay in providing A with an in-person appointment was brief and were unable to conclude that the delay had a material impact on A’s prognosis.

In the circumstances, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that there was an unreasonable delay in providing A with a face-to-face appointment. 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 the staff involved, 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 to us about the care and treatment their adult child (A) received from the board regarding their mental health over a one-year period. A was an in-patient for part of this time and C complained that it was inappropriate to allow A to make decisions about their care, including time out of the ward. C raised concerns about A’s diagnosis and the medication they were prescribed, as well as the level of support in place for A.

We took independent advice from a psychiatrist. We found that the care and treatment provided to A in relation to their mental health was reasonable and in line with relevant guidance. We also found that the symptoms exhibited by A were consistent with their diagnosis and that the medication put in place for A was reasonable. We did not uphold this complaint.

C also complained that the care and treatment A received regarding their physical health whilst an in-patient had been unreasonable. We found that the approach taken during A’s admission to hospital was reasonable and in line with the expected approach. The focus of clinicians was on A’s psychiatric symptoms and their physical health was treated in line with the arrangements already in place for them in the community. It was reasonable for the referral to rheumatology (specialists in rheumatism, arthritis, and other disorders of the joints, muscles, and ligaments) to be passed to A’s GP on discharge. We did not uphold this complaint.

In addition, C complained that the communication and engagement with them with regards to input into A’s care and treatment had been unreasonable. We found that the communications recorded in A’s medical notes were of an appropriate standard and well recorded. We did not uphold this complaint.