Health

Summary

C complained that the board failed to carry out an endoscopic retrograde cholangiopancreatography (ERCP, an imaging test involving a combination of endoscopy and X-rays for examination of the bile ducts and pancreas) procedure reasonably which resulted in a retroperitoneal perforation (a tear in the lining of the abdomen) and post-ERCP pancreatitis (inflammation of the pancreas).

We took independent advice from a consultant gastroenterologist and hepatologist (a physician who specialises in the diagnosis and treatment of disorders of the gastrointestinal tract, liver, pancreas and gall bladder). We found that the ERCP was a necessary procedure in C's case, that the perforation and post-ERCP pancreatitis are recognised complications and that appropriate measures were taken to reduce the risk of post-ERCP pancreatitis by administering diclofenac (a non-steroidal anti-inflammatory or NSAID). We did not identify any unreasonable failings regarding C's care and we did not uphold this complaint.

C also complained that they were not informed of the risks of the ERCP (including pancreatitis or duodenal perforation) and that following the ERCP, the tear was not mentioned to C by the consultants and that they were given different stories by them. We took independent advice from a consultant general surgeon. We found that the communication with C regarding the findings of the CT scan (a tear in the lining of the abdomen) was reasonable. We also found that an information booklet was attached to the consent form when it was signed, and that C was appropriately made aware of the risks and complications associated with the procedure. However, we noted that it would be good practice to keep a copy of the information booklet in the medical records and we included this in our feedback for the board. We did not uphold C's complaint regarding the board's communication.

Summary

C sustained severe and multiple injuries to their wrist and pelvis following a road accident. C underwent numerous surgical procedures on their wrist and complained that the care and treatment they received was unreasonable. C felt that due to the placement, the screws that were used caused greater damage. C also said that the board chose not to undertake any further surgery to treat the ongoing pain and limited range of movement that C experienced.

We took independent advice from an appropriately qualified medical adviser. We found that the board provided reasonable emergency care to C immediately after their accident. The surgery carried out was reasonable, with the screws and plates appropriately placed, given the type of injury that C had. We also found that it was reasonable for the board to decide to end the first operation (due to operation length) and undertake further surgery to complete their treatment of C's wrist, and that C's discharge was appropriate. We did not uphold this complaint. However, we noted that earlier counselling around the significance of an injury like this and making sure that C did not have unrealistic expectations, may have been helpful in this case. We provided feedback to the board on this point.

Summary

C complained on behalf of their parent (A) that the care and treatment they received from the board was unreasonable and led to a delay in A being diagnosed with colon cancer. A was urgently referred to the board from their GP with a suspicion of inflammatory bowel disease. An initial appointment for the gastroenterology (medicine of the digestive system and itsdisorders) outpatient clinic was scheduled for six weeks from the date of receipt of the referral but this was cancelled and delayed for a further six weeks. However, A did not require to wait this period of time due to an emergency admission to Inverclyde Royal Hospital (IRH). A was later discharged with a view to them returning for a colonoscopy (examination of the bowel with a camera on a flexible tube) in four weeks. Before the colonoscopy was carried out, A was readmitted to IRH with deterioration of their symptoms which required emergency surgery and A's cancer diagnosis was made.

We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines). We found that, as the referral was not for suspected cancer but for inflammatory bowel disease, the initial six week wait was reasonable. However, a wait of nearly three months would have been unreasonable in view of the severity of A's symptoms and the urgency of the referral. The board have acknowledged this delay. We were unable to conclude if A's outcome would have been different had they been seen at an outpatient gastroenterology clinic as initially arranged.

In relation to A's admission to IRH, we found that the care was reasonable and in line with accepted practice. We also found that it was reasonable to discharge A without performing a colonoscopy at that time, so as to allow inflammation to settle and reduce the risks of complications related to performing such a procedure. We concluded that A's case was an unusual presentation of colon cancer.

On balance, we considered that there was an unreasonable failure in A's care and treatment but only in relation to the delay in the gastroenterology referral. As such, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the unreasonable delay in the time they waited for a gastroenterology outpatient appointment. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

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

• Where a referral appointment is to be delayed, there should be a process of reviewing the referral to assess the appropriateness of such delay.

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) in A&E. We took independent advice from an accident and emergency adviser. We found that A waited an unreasonable amount of time for a clinical review on their attendance to A&E and this did not meet the triage category standards assigned to A. We also found that sepsis (blood infection) should have been considered at an earlier stage during one of A's attendances to A&E given their low blood pressure and increased respiratory rate. We upheld this aspect of C's complaint.

C complained that the board failed to provide A with reasonable care and treatment regarding a chyle leak (an accumulation of lymphatic fluid in the abdominal cavity). We took independent advice from a surgical adviser. We found that A was provided with reasonable care and treatment for the chyle leak, that their pain and discomfort was appropriately investigated and responded to and that reasonable action was taken in relation to the prevention of blood clots. As such, we did not uphold this aspect of C's complaint.

Finally, C complained that A's mobility was not fully investigated while they were in hospital. We took independent advice from a physiotherapy adviser (a person qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise). We found that A was provided with reasonable care by physiotherapists in the assessment and management of their mobility. We 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 considering sepsis at an earlier stage during A's attendance to A&E given their low blood pressure and increased respiratory rate. 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 should receive a clinical review within triage category timescale.
• Sepsis should be considered in A&E patients who present with low blood pressure and increased respiratory rate.

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 there was an error in carrying out their child (A)'s dental surgery at the Royal Hospital for Children. A had been referred by an orthodontist (medical professional dealing with the prevention and correction of irregular teeth) to have two teeth removed. C raised concerns that they had removed the wrong tooth (A's front tooth) and left in the two teeth they were supposed to remove.

The board said that their oral and maxillofacial surgery clinicians (OMFS, specialists in treating diseases and injuries of the mouth and face) had appropriately reviewed A's original treatment plan. The board explained that their OMFS clinicians had tried to contact the orthodontist to explain that A's original treatment plan was not clinically possible.

We took independent advice from a consultant OMFS. We found that A's treatment plan should not have been changed without consulting the referring orthodontist and agreeing the changes with them. We found that the clinical rationale for changing A's treatment plan was not clearly recorded. We also found that the changes were not communicated clearly enough to C and A in a manner that they could understand. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A's care and treatment. 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 should be given complex information in a way that they can understand and clinicians should check their understanding.
• The reasons for clinical decisions should be clearly recorded. This includes recording any discussions with senior staff that inform clinical 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 complained about the treatment that their parent (A) received at the ophthalmology department (the branch of medicine concerned with the study and treatment of disorders and diseases of the eye) at Aberdeen Royal Infirmary. A had been referred to the hospital by two opticians who believed that A's eyes required a review from hospital specialists. Following the consultation, A was told to use a magnifying glass but that further medical intervention was not required. However, A continued to have problems with their sight within the next year and while abroad had to seek emergency medical review. A had to have surgery for the removal of both cataracts (when the lens, a small transparent disc inside the eye, develops cloudy patches). C believed that A did not receive appropriate treatment at the consultation and that consideration should have been given to the removal of their cataracts.

We took independent clinical advice from an ophthalmologist (a doctor who examines, diagnoses and treatsdiseases and injuries in and around the eye). We found that A was appropriately assessed and treated and at that time there was not a clinical need or indication for eye surgery. It appeared that A's sight deteriorated following the consultation and that could not have been predicted.

We did not uphold the complaint.

Summary

C complained about the treatment provided to their late parent (A) by their GP practice. A had prostate cancer for a number of years which later spread to their liver.

C complained that the practice failed to reasonably monitor A's blood sugar levels (HbA1c) after prescribing medication. We took independent advice from a GP. We found that the decision to commence medication for A's raised HbA1c was reasonable and appeared to be made with the input of a specialist medical consultant. However, there was no record to indicate that the practice discussed the risks of hypoglycaemia (low blood sugar) with A or took steps to allow A to monitor their blood sugar levels. We considered that the responsibility of monitoring any risks from the medication fell to the practice. Therefore, we upheld this aspect of C's complaint.

C complained that the practice failed to reasonably respond to A's reduced haemoglobin (Hb) levels. We found that, while the actions taken after the blood test results reported two weeks prior to A's death were reasonable, there was an opportunity prior to that to act on A's falling Hb levels. We noted that given the trend of A's falling Hb levels and their overall clinical picture, there was a fair to good chance that A's condition would deteriorate prior to a scheduled admission for a blood transfusion. We considered that the decision not to admit A prior to the scheduled admission, was a doctor-led decision rather than one made in conjunction with A and their family's wishes. As such, we upheld this aspect of C's complaint.

Finally, C complained that the practice failed to reasonably manage A's pain and comfort. We found that the pain management was reasonable and that the practice provided a high standard of palliative care. The medications administered, the timing of them and the increases in dosage were in keeping with the recommended standards of care, and in keeping with A's needs. Therefore, we did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably manage A's blood sugar levels after prescribing medication and the delay in responding to A's falling Hb levels. 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:

• Decisions about admission for treatment should be made in conjunction with the patient's and family's wishes.
• The practice should discuss with patients the risk of hypoglycaemia, or the institution of finger prick monitoring when instigating medication affecting HbA1c. The patient should be counselled about the risk and this should be recorded.
• Trends towards falling Hb in a patient with cancer should be noted and acted on timeously.

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 provided to their parent (A) by the board. A had prostate cancer for a number of years. A's symptoms worsened in the period complained about and it transpired that the cancer had spread to A's liver. C considered that the care and treatment provided by the board in the period prior to A's death was unreasonable, with the board failing to reasonably respond to A's worsening condition.

We took independent advice from a consultant in palliative medicine (caregiving approach aimed at optimising quality of life and reducing suffering among people with serious, complex illness), a registered general nurse and community health specialist nurse practitioner.

C's first complaint was that the board failed to reasonably respond to A's reduced haemoglobin levels. We found that A's haemoglobin levels were appropriately managed with regular review and assessment of symptoms, and the prescribing and monitoring of 'safer' medication before planning a transfusion. We noted that there was appropriate escalation of the transfusion date once doctors became aware that the haemoglobin had fallen further. Based on A's condition at the time, the initial planned date of admission for transfusion was reasonable. As such, we did not uphold this aspect of C's complaint.

C complained that the board failed to reasonably manage A's pain. We found that the levels of pain medication prescribed were reasonable. We noted that pain was not identified as a problem or symptom during A's hospital stay, therefore, discharge without regular morphine medication was reasonable. On discharge, the board appropriately handed over care to the GP, the local hospice and community palliative care. We found that when A exhibited pain, they were reviewed in line with guidance and appropriate medication was prescribed. District nurses administered pain medication through the 'just in case' medications prescribed while A was at home. As such, we did not uphold this aspect of C's complaint.

C complained that the board failed to reasonably discharge A from hospital. We found that, while the decision to discharge A was a reasonable one, and most services were appropriately notified of A's discharge, district nurses were not, impacting on the support provided by this service immediately after discharge. There was also a failing in providing a reasonable level of support for A to dress immediately prior to discharge. As such, we upheld this aspect of C's complaint. We noted that the board were sorry that more support was not offered.

C complained that the board unreasonably failed to provide a new mattress in a timely manner. We found that, while the delay in notifying the district nurses of the arrival of the mattress was unfortunate, we accepted that the board provided a mattress within 24 hours which was a reasonable response to an equipment request. We accepted that the district nurses were unaware of delivery on the day of delivery but once they became aware, a plan to transfer A was put in place. We considered that the delay in transfer was due to a holistic assessment of A's needs at that time which was appropriate in the circumstances. As such, on balance, we did not uphold this aspect of C's complaint.

Finally, C complained that the board failed to provide reasonable nursing care when transferring A to the new mattress. We found that the board had provided reasonable nursing care when transferring A onto the mattress, based on the records available. We noted that pain medication was administered prior to the transfer, which was reasonable. As such, we did not uphold this aspect of C's complaint. However, we noted that there was limited documentation of the event and fed this back to the board.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A's discharge. 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:

• Referrals to the palliative care team should contain all relevant information.
• The rapid discharge algorithm for last days of life should be followed for future discharges.
• When there is the presence of confusion and/or deteriorating function in a patient, assistance should be considered to ensure a patient is dressed appropriately before leaving the ward.

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 that they received after they underwent a minor surgical procedure as a day patient at Forth Valley Royal Hospital. C said that after the procedure they did not recover well from the anaesthetic (drugs administered to cause numbness of pain) and experienced severe chest pain. Despite this, they said that staff had tried to discharge them before they had properly recovered from the anaesthetic and that staff had ignored the symptoms they were experiencing. C said that they had experienced a heart attack and were later admitted to the Intensive Care Unit (ICU). They complained about the conduct of staff while they were there and that they acted inappropriately.

We took independent advice from a consultant anaesthetist (a medical specialist who administers anaesthetics) and a nursing adviser. We found that, while there was a lack of detail in the clinical records, the evidence available demonstrated that the anaesthetic for the procedure had been given in accordance with good practice and guidelines and doses of drugs were appropriate. In particular, there was no evidence of over dosage of general anaesthetic drugs. We noted that there may have been some delay in recognising that the chest pain C was experiencing was not resolving, however, this had no effect on the outcome and when investigations showed that some heart muscle damage had occurred, appropriate treatment was started. We also found that the nursing care given to C had been reasonable and that the nursing notes were completed to a good standard. We noted that the board had apologised that C felt that a member of staff's attitude had been dismissive and also for the behaviour of staff in ICU.

We considered that the care and treatment given to C was reasonable and did not uphold the complaint. However, having reviewed the handling of the complaint, we concluded that the board failed to appropriately investigate and respond to C's complaint. In particular, that there had been a failure to obtain a formal report from the anaesthetist in response to C's original complaint. Therefore, we made a recommendation under section 16G of the SPSO Act 2002, which requires the Ombudsman to monitor and promote best practice in relation to complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to fully investigate and respond to their complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Relevant staff should be aware of the requirements of the complaints handling procedures, particularly regarding collating and assessing relevant evidence in determining a complaint.

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 nursing care that they received whilst an in-patient at Forth Valley Royal Hospital. C complained that during their stay in the hospital there were errors in the administration of their medication and that they were manhandled by a member of staff when trying to get out of bed. They also said that there was a delay in providing pain relief after this incident.

We took independent advice from a nursing adviser. We found that, overall, the care given to C with regards to moving and the handling of pain control was reasonable. However, while we found no evidence that their medication dosages were incorrect and we were satisfied that C's medication was given as appropriate, there was an occasion when a prescribed dose of morphine was not recorded as being given. While we had no reason to doubt C's recollection of events which had led to them complaining they had been manhandled, there was no record of the incident in the clinical records and the staff member's recollection was different to C's account of what happened. However, C's pain score had not been checked at this time and had it been checked, this may have shed a light on the matter. We found that the failure to record C's pain score was unreasonable.

On balance, because of the failure to administer all C's morphine doses as prescribed and because of the failure to record C's pain score, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to administer slow acting morphine as prescribed or record the reason why it was not given and for failing to record pain scores on the morning specified. 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:

• Pain scores should be recorded appropriately and in a timely manner.
• All medication prescribed should be recorded as being given or where medications are not administered, reasons for this should be documented.

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.