Health

Summary

C complained about the care and treatment provided to their late spouse (A) who had a history of superficial bladder cancer (early bladder cancer when the cancer cells are only in the inner lining of the bladder and has not spread beyond it) and prostate cancer. C complained about the care and treatment provided during two short admissions to Borders General Hospital. A was passing blood in their urine and had unexplained pain. C specifically complained that A was not thoroughly assessed and that further investigations should have been carried out. A chest x-ray was later performed which identified a shadow on A’s lung. A’s condition deteriorated and they died a few weeks later.

The board confirmed that they considered the care and treatment provided to be reasonable and that there was no suggestion at the time to indicate that further tests were necessary.

We took independent advice from a consultant uro-oncologist (a specialist in diagnosing and treating cancers of the male and female urinary tract and the male reproductive organs) with a speciality in dealing with bladder and prostate cancer. We found that there was a failure to take the appropriate action in response to the findings of a previous cystoscopy (bladder examination using a narrow tube-like telescopic camera) which showed a thickened bladder, and that during the first admission it was incorrect to state that the findings of this procedure were normal. We also considered that the board failed to fully investigate the cause of A’s bleeding, nor the thickened bladder, and that not enough regard was given of A’s deterioration. We upheld the complaints, concluding that these failings led to a delayed diagnosis of A’s cancer. However, we acknowledged that these failings did not impact on A’s ultimate prognosis.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the identified failings. 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:

• Staff should fully understand the importance of taking into account the patient’s medical history, accurately report on previous test results and ensure that symptoms are 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 they received from the practice was unreasonable. C said that they had developed an intolerance to a number of medications, some of which they had previously tolerated. C sought a referral to pharmacology (the branch of medicine concerned with the uses, effects, and modes of action of drugs) through the practice but complained that they unreasonably failed to facilitate this.

C complained that the GPs at the practice were dismissive of C’s symptoms without reasonable investigations being carried out. C said that their symptoms were inappropriately attributed to anxiety or panic attacks and that GPs provided misleading information in referrals that suited their own presumptions about C’s diagnosis.

We took independent advice from a GP. We found that, whilst the GPs and C disagreed about the likely cause of C’s symptoms, the GPs did not rule out C’s opinion or block their access to specialist investigations. We were satisfied that the practice’s GPs made referrals based on their assessments of C’s symptoms, but put forward C’s opinion for consideration by the receiving specialists.

We were satisfied that the practice’s GPs made appropriate referrals and did not promote their own ideas about C’s likely diagnosis. Whilst we considered that one of the GPs could have communicated more clearly with C about the reasons behind one of the referrals, overall, we found the care and treatment provided by the practice to be reasonable. We did not uphold this complaint.

Summary

C attended A&E at Perth Royal Infirmary following a knee injury. They were diagnosed with a soft tissue/tendon strain and advised to attend their GP for follow-up. C said that their knee did not settle and attended the hospital again six months later. C was then told that they had a meniscal tear (a partial or full tear in the cartilage of the knee). As their condition did not improve, C underwent an operation. C said that they experienced no relief following the operation and their GP made a further referral to orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system). They were advised that further surgery would be unlikely to help and, therefore, there was no clinical reasons to operate further.

C complained about the care and treatment they were given by the board. C said that there was a delay in providing appropriate treatment and diagnosis, that their care was poor and that the board did not deal reasonably with their complaints about this.

The board said that C’s initial care and treatment had been appropriate and although they were aware of C’s view that they should have been x-rayed when they first attended the hospital, to have done so would not have shown the subsequent diagnosis they received. The board added that scans and x-rays were not routinely carried out for knee injuries and that C had been given appropriate advice.

We took independent advice from consultants in emergency medicine and in orthopaedics. We found that, overall, C’s care and treatment had been reasonable. However, there was a failure to carry out an x-ray when they first attended hospital which was contrary to accepted guidance regarding when an x-ray of a knee should be undertaken following trauma. For this reason, the complaint was upheld.

In relation to complaint handling, we found that C was kept fully apprised of the progress of their complaint and given a new target date for a response which was met. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to x-ray their knee in accordance with the Ottowa knee rules. 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:

• When presented with knee injuries in A&E, clinicians should take into account the relevant guidance (in this case the Ottowa knee rules).

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 late partner (A) tested positive for COVID-19. A week after testing positive, A called 111 as they were still feeling very ill. They explained that they had had a fever for a few days and were having difficulty regulating their temperature. A was advised by a nurse practitioner to remain hydrated, continue taking paracetamol, and to continue to self-isolate until they had no fever for 48 hours. They were also advised to call back if they had any further concerns about their symptoms.

C called 111 again a few days later as they were concerned A’s breathing was becoming laboured. C had to wait around 20 minutes before the call was answered. During the call, the call handler repeatedly asked to speak to A to take information directly from them, even though C kept answering for A as A was confused. The call lasted around 30 minutes. The call handler contacted Scottish Ambulance Service and requested an ambulance on an emergency basis, but by the time paramedics arrived A had stopped breathing and could not be resuscitated. C complained about the clinical assessments of A’s condition on both instances.

We took advice from an advanced nurse practitioner with experience of assessing patients with similar presentations. We found the assessment on the first instance to be reasonable, and we therefore did not uphold this complaint.

We considered it unreasonable for the second call to have lasted 30 minutes before an ambulance was called. We noted that the call handler was following the protocol correctly, but were of the view that if the protocol took 30 minutes to establish that an emergency response was required, it was not fit for purpose. We considered that rigid following of the protocol led to a delay in obtaining medical attention for A. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings we have 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:

• Protocol is reviewed so that in patients with shortness of breath as the primary presentation there is a clear escalation route to a medically trained clinician.

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 removed from their GP practice patient list. The practice were contacted by Practitioner Services (part of NHS National Services Scotland who support primary care providers) after this and suggested the practice refer C to the board's Challenging Behaviour General Practice (CBGP). The practice referred C to the CBGP.

C complained that the practice had unreasonably referred them to CBGP. C said the practice were not required to refer C to CBGP, did not have a good reason to refer them and did not follow the correct procedure.

We found that once the practice’s request to have C removed from their patient list was actioned, they were not obliged to arrange any future care for C. However, Practitioner Services found themselves unable to place C on a patient list of another GP practice in the area. They went back to C’s most recent practice and asked them to refer C to the board’s CBGP. The referral the practice sent meant C might (if the referral was accepted) have access to primary care services. We decided that the decision to refer C to CGBP was reasonable in the circumstances. As such, we did not uphold this complaint.

However, we found that the processes in place were not helpful to guiding the situation C found themselves in. Understandably C was left confused about why the referral was made and had to contact the practice themselves to find this out. We passed on our feedback to the relevant health board.

Summary

C complained about various aspects of the care and treatment their late spouse (A) received from the board.

A had a history of vascular (relating to a vessel or vessels, especially those which carry blood) surgery and was admitted to hospital for the removal of a benign tumour. The procedure took place, however, A’s condition deteriorated and they were moved to an infectious diseases unit with suspected sepsis (blood infection). A’s condition deteriorated further and they were transferred to a vascular and critical care ward in a different hospital on an emergency basis. Later that day, A underwent surgery to remove an infected synthetic artery graft (a piece of living tissue that is transplanted surgically).

A experienced an abdominal bleed and was transferred to a critical care unit. After treatment, A was reviewed by a consultant and returned to the vascular and critical care ward. A experienced a fall on the ward. A later developed a lung infection/sepsis and died.

C complained that the board failed to screen, manage or treat A’s infection. C said that A had been discharged from the critical care unit onto the ward too soon. C also complained that the board had failed to properly assess A’s fall risk or treat A properly after their fall.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a registered nurse. We found that the screening, management and treatment of A’s infection and their discharge from the critical care unit was reasonable. We did not uphold these complaints. However, we found that the board had failed to adequately complete risk assessments, including a falls risk assessment, for A. We upheld this complaint.

We also considered that the board made an error of communication while responding to C’s complaint when they referred to MRSA (a bacterial infection that is resistant to a number of widely used antibiotics) instead of MSSA (a bacterial infection which is not resistant to certain antibiotics). We provided feedback to the board about this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for wrongly referring to MRSA rather than MSSA when responding to C’s complaint and for their failure to complete A’s Falls Risk Assessment; bed rails and 4AT delirium assessments in line with organisational policy. 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:

• Falls Risk Assessments and bed rails/4ATdelirium assessments should be carried out in line with the board’s stated policy.

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 the board about surgery they received on a semi-urgent basis. C complained that the surgery had been inadequate and that they had been unable to fully consent to it due to time pressure and a lack of information. C also complained that the board’s subsequent management of their pain medication was unreasonable. In particular, C complained that they had not been informed of the potential for opiate pain relief to become habit-forming. The board responded that the surgery had been performed correctly and that a lengthy consultation had been held with C prior to surgery by the operating consultant neurosurgeon (a surgeon who specialises in surgery on the nervous system, especially the brain and spinal cord).

We took independent advice from a consultant neurosurgeon. We found that the surgery had been performed to a reasonable standard and that the board’s management of C’s pain medication was also reasonable.

However, we identified a lack of records illustrating any discussion with C about the potential benefits, risks or complications of surgery prior to the operation. We also identified a lack of records illustrating any discussion with C regarding the potential for opiates to become habit-forming.

In the absence of such records we were unable to say whether C received appropriate information. Therefore, on balance, we upheld both complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that there was no contemporaneous evidence that C was reasonably informed of the potential risks and complications of surgery or of the potential for morphine to become habit-forming. 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 complete records of discussions with patients about the potential risks and complications of surgery prior to surgery.
• There should be records of discussions with patients regarding the potential for morphine to become habit-forming.

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 brother (A). A’s consultations with the practice took place when COVID-19 restrictions were in place and as such, a number of their appointments were held via phone.

A had been complaining of a persistent sore throat and tongue. A also said that they had been reporting a lump in their neck. A was referred to the Ear, Nose and Throat (ENT) department and was diagnosed with oropharyngeal cancer (a type of cancer that begins in the cells of the tonsils). C complained that there was a delay in referring A to ENT for further investigation.

We took independent advice from a GP. We found that there was a poor standard of record keeping by the practice. The records did not always demonstrate that an adequate medical history was obtained or that adequate safety netting and follow-up advice was provided. We also identified that the wrong antibiotics were prescribed on one occasion and that the wrong test for glandular fever was performed. We were concerned that the practice’s own investigation of the complaint did not identify any of these failings.

We considered that there was likely a delay of 15 days in referring A for further investigation. While this was not significant, in light of the other failings identified, we upheld the 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:

• The medical centre should ensure that staff are confident and knowledgeable in carrying out physical examinations.
• The medical centre should ensure that the Significant Event Analysis addresses both clinical care and treatment and internal processes.
• The medical centre should ensure the standard of record-keeping meets General Medical Council Good Medical Practice standards.
• The medical centre should have a policy to review their cases or seek medical advice, especially when several consultations occur and the case is non-responsive or atypical.

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's community mental health team recorded their transgender status in their medical records, without C's knowledge or consent. In their complaint response, the board said that they considered C's gender transition was relevant to their mental health treatment and medical staff would require access to the information when providing C with treatment.

We took independent advice from appropriate clinical specialists. We found from a clinical perspective that, at the time the information was recorded, it had been reasonable for staff to conclude that consent had been given as this information was provided by C, and that the information was relevant to the treatment being provided and, therefore, reasonable to record. We did not uphold this complaint.

However, we did not make a decision on specific points raised about the ongoing and future management of personal data in the records as we considered these were ultimately more appropriate for the Information Commissioner’s Office.

Summary

C underwent re-root canal treatment from the dentist in an attempt to treat an abscess (a painful swelling caused by a build-up of pus) which had formed under one of their teeth. After attempts to resolve the issue were unsuccessful, C was referred to a specialist. C complained that the re-root canal treatment was not carried out by the dentist in a reasonable manner and limited further treatment options for C.

We took independent advice from a specialist in dentistry. We found that the treatment provided was reasonable. While the treatment did not resolve the presence of C’s abscess, it was not unreasonable.

As such, we did not uphold this complaint.