Health

Summary

C underwent a septoplasty (procedure to straighten bone and cartilage in nose). Around nine years later, C was referred to neurology (the science of the nerves and the nervoussystem, especially of the diseases affecting them) with symptoms of migraine. C believed that their pain and symptoms were related to physical issues with their nasal passages, rather than being neurological in origin.

C underwent an MRI scan to investigate their history of recurring pain and headaches. The board's conclusion was that there was no abnormal findings and ruled out issues with C's septum and nasal passages being the cause of their symptoms. C complained to the health board that the findings from the MRI scan were incorrect and that the board refused to offer C a second opinion.

The health board responded to C's complaint advising that the results of the MRI were reported accurately and that there was no evidence of failures with respect to the assessment of the imaging. Repeat imaging was arranged but C cancelled the appointment and advised that they did not want this to go ahead.

C brought the complaint to us that the health board had failed to appropriately assess the MRI scan and take appropriate action to resolve their symptoms. We sought advice from an independent adviser and we found that the board appropriately assessed the MRI scan and took appropriate action for follow-up imaging to be arranged. We identified that it may have been beneficial had the health board clarified the deviated septum identified in the imaging was considered incidental and therefore not included in the imaging report. This was fed back to the board. Given that the assessment and treatment was reasonable, we did not uphold the complaint.

Summary

C complained on behalf of their spouse (A) about the treatment they received from the board. A was originally referred to a consultant obstetrician and gynaecologist (specialist in pregnancy, childbirth and the female reproductive system) at a different health board. Following further investigations, A's case was discussed at a multidisciplinary team meeting (MDT) which includes specialists from health boards in the west of Scotland. As Glasgow has a subspecialty in gynaecological cancers, Greater Glasgow and Clyde NHS Board took the lead in determining A's treatment plan. A was diagnosed with probable ovarian cancer and was treated with chemotherapy and surgery.

C complained about a delay in starting A's treatment, about the decision not to offer chemotherapy first and about how the board responded to their contacts during this time.

We took independent advice from a consultant gynaecological oncologist (cancer specialist). Scottish Government guidance, NHS Scotland performance against Local Delivery Plan standards, says that 95% of all patients diagnosed with cancer are to begin treatment within 31 days of decision to treat. A's treatment was not provided until 40 days later (nine days more than the guidance). Greater Glasgow and Clyde NHS Board were responsible for meeting this target, and it was not met. We upheld this complaint.

We found that while some clinicians would have treated with chemotherapy first, it was also completely acceptable practice, and indeed encouraged by relevant clinical guidelines, to provide surgery first. We did not uphold this complaint.

We considered the communication between C, A and the board. We found that while not every contact was responded to as quickly as the board said it would, and some communication was passed on without acknowledgement, the board did respond to the substantive questions C and A raised and had appointed a single point of contact to help communication going forward. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to meet the Local Delivery Plan standard. The apology should meet the standards set out in the SPSO guidelines on apology available 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 complained about surgery carried out by the board. C underwent abdominal surgery and immediately after the procedure, experienced issues and severe abdominal pain.

C was made aware by the surgical staff that there had been complications during the operation, but was advised that this would not have caused the issues. C underwent a second procedure and a diagnosis was made during this surgery.

C complained about the board's handling of the first operation and the surgeon's failure to make a diagnosis during the first procedure. We found that, whilst there were complications during the first procedure, these occurred despite the board's staff taking all reasonable precautions. We accepted advice that, due to the nature of C's condition, it was not unreasonable that no diagnosis was confirmed during the first procedure. We could find no clear link between events during the first surgery and the problems C later experienced. We did not uphold C's complaints.

Summary

C complained to us about the care and treatment provided to their parent (A). A was admitted to Inverclyde Royal Hospital after they had fallen at home. The following night, A had an unwitnessed fall in the hospital. Around ten days later, A's leg was noted to be at an odd angle and A was found to have a fractured hip.

C complained about the nursing care A received. We took independent advice from a nurse and an orthopaedic consultant (a specialist in the treatment of diseases and injuries of the musculoskeletal system).

We found that A's initial falls risk assessment was unreasonable and A's family was not informed about A's fall. We upheld this aspect of the complaint. However, we noted that the board had already taken action to address failings in nursing care they had identified.

C also complained about the medical care A received. We found that after A fell both at home and at the hospital, appropriate medical examinations were not carried out and/or documented. We found it was highly likely this led to a delay in identifying A's hip fracture and in treating it. We also found that when A had hip surgery, there was no record that the risks of general anaesthetic had been discussed with A or their family. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A's nursing care (in relation to their initial falls risk assessment and their 'getting to know you board'); and the failings identified in A's medical 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 clear information about the risks of general anaesthetic; and the discussion should be clearly recorded.
• Patients who have fallen should be given appropriate medical examinations, which are clearly 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.

Summary

C complained about a number of different aspects of the board's communication with them. Firstly, C complained about how the outcomes of two magnetic resonance imaging (MRI) scans were communicated to them. In respect of one scan, a consultant neurologist (specialist in the diagnosis and treatment of disorders of the nervous system) advised there had been “no change”. A later scan was then described as “unchanged over time”. After C obtained their medical records, they concluded that there were changes identified in both of the MRI scans.

We took independent advice from a consultant neurologist. We found that it was reasonable to describe the results as unchanged. We noted that most clinicians would, on receiving a report which described changes in a lesion which were of no clinical significance, report to the patient that there was no change. We understood why C may consider the information passed to them to be inaccurate compared to the more detailed records they obtained through a subject access request. However, we concluded that the results of the MRI scans were communicated to C in an acceptable manner and the board did not fail to carry out any follow-up actions that they should have. Therefore, we did not uphold this complaint.

C also complained about the board's communication with them following a consultation with a consultant ear, nose, throat and skull base surgeon. C had been referred by another consultant for a second opinion. Following the consultation, the consultant wrote to the referring consultant and copied in C's GP. However, C did not receive any communication about the outcomes of the consultation and their GP advised them that it is not a GP's responsibility to share results of tests initiated by a secondary care doctor with patients. In C's view, the board should have communicated the outcome of the consultation to them directly.

We found that local policies and procedures may affect how outcomes of consultations are communicated to patients. We were satisfied that the board appeared to agree that it is not a GP's responsibility to relay such outcomes to their patients. However, we would expect the patient to be copied into documentation unless there is a specific reason not to. We considered it unreasonable that the outcomes of the consultation were not communicated directly to C in some form. As such, we upheld this complaint.

Finally, C complained that the board failed to respond reasonably to their complaint. In C's view, the board's stage 2 response did not address several important points of their complaint and contained inaccuracies. We considered the board's stage 2 response to be a broadly reasonable and good faith attempt to address C's concerns. However, we concluded that there were specific aspects of the board's stage 2 response that undermined their efforts to address C's concerns. Firstly, a poorly worded statement caused it to be fundamentally inaccurate and confusing. Secondly, in some instances, the board failed to provide direct responses that tied clearly into C's complaint points. Given these shortcomings, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide a reasonable response to certain aspects of their complaint and for failing to communicate the outcome of their ear, nose and throat consultation directly to them. 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 ensure that the outcomes of consultations carried out by secondary care clinicians are communicated to the patient in an appropriate and recognised method. It should not be assumed that the patient's GP will forward any correspondence to them.

In relation to complaints handling, we recommended:

• In line with the Model Complaint Handling Procedure, stage 2 complaint responses should be clear and easy to understand, and address all the issues raised and demonstrate that each element has been fully and fairly 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 on behalf of their spouse (A). A was urgently referred to a consultant obstetrician and gynaecologist (specialist in pregnancy, childbirth and the female reproductive system) at Forth Valley NHS Board. Following further investigations, A's case was discussed at a multidisciplinary team meeting (MDT) which included specialists from health boards in the west of Scotland. A different health board took the lead in determining A's treatment plan. A was diagnosed with probable ovarian cancer and was treated with chemotherapy and surgery.

C complained about a delay in starting A's treatment, about the decision not to offer chemotherapy first and about how the board responded to their contacts during this time.

We took independent advice from a consultant gynaecological oncologist (cancer specialist). Scottish Government guidance, NHS Scotland performance against Local Delivery Plan standards, says 95% of those referred urgently with a suspicion of cancer to begin treatment within 62 days of receipt of referral. From A's urgent referral to the start of treatment was 63 days, one day more than the guidance. As Forth Valley NHS Board was responsible for meeting this target but did not meet it, we upheld this complaint.

We found that while some clinicians would have treated with chemotherapy first, it was also completely acceptable practice, and indeed encouraged by relevant clinical guidelines, to provide surgery first. We accepted this advice and did not uphold this complaint.

We considered the communication between C, A and the board. We found that while not every contact was responded to as quickly as the board said it would, and some communication was passed on without acknowledgement, the board did respond to the substantive questions C and A raised. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to meet the Local Delivery Plan standard. The apology should meet the standards set out in the SPSO guidelines on apology available 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 complained that the care and treatment provided to their partner (A) was unreasonable. During a routine scan around 20 weeks into A's pregnancy, their cervix was found to be short, putting them at risk of miscarriage. A suture (a stitch or row of stitches holding together the edges of a wound or surgical incision) was inserted in their cervix that day. In hospital the following day, it appeared that A's membranes had ruptured and that the decision was taken to remove the suture. A and C were advised their baby was unlikely to survive. They were offered medication to abort the foetus and condolences were given. They chose to continue with the pregnancy and as time passed it appeared that the initial diagnosis had been incorrect. A was monitored for a few days on the ward and was discharged with follow-up arrangements when their condition was deemed to be stable.

At a follow-up appointment a few days after discharge from hospital, the consultant advised that a further suture was required to protect the pregnancy. The procedure was carried out that day. A few weeks after the second suture was inserted, A went into labour and their baby was born three months prematurely.

C complained that the decision to remove the first suture was unreasonable. They also complained that they had been told their unborn baby was dead.

We took independent clinical advice from a consultant obstetrician and gynaecologist (specialist in pregnancy, childbirth and the female reproductive system). We found that in deciding to remove the suture the clinicians were acting in good faith with the information available and in the best interests of the mother, at a stage when the foetus could not survive if delivered. Appropriate discussion took place with the on-call consultant who was in agreement with the instruction that the suture should be removed if there was any sign of ruptured membranes. This is a recognised indication for removal of a cervical suture as it increases the risk of maternal sepsis (blood infection).

Given the likelihood that the patient would go on to miscarry, we found that it was appropriate to offer condolences. We found no evidence in the notes that staff told the patient their baby was dead. The adviser noted that the foetal heart was heard using sonic aid and that the patient reported feeling foetal movements.

Therefore, we did not uphold either complaint.

Summary

C complained that the practice had unfairly accused them of being threatening and aggressive, resulting in their removal from the practice list and that C had been unreasonably placed on an opiate reduction programme. C said that they had been targeted because they had successfully complained about the services provided by the practice in the past. C said that the practice had misrepresented the opiate reduction as mandatory, when in fact they were only required to review opiate use. C said that the practice had not taken into account the impact of the opiate reduction on them.

The practice said that they had a zero tolerance for aggressive or inappropriate behaviour. C had abused the prescription request service and had entered the practice and refused to leave unless they were provided with an additional prescription. The practice had, after review, reinstated C to the practice, but C had continued to request medication early, breaching their agreements with the practice. This had resulted in their removal from the practice lists. The practice had reviewed and reduced C's medication in line with best practice and health board guidance. C had previously sought medication early and was considered by the practice to meet the criteria for opiate reduction.

We took advice from an independent medical adviser. We found that the practice had acted reasonably in seeking to reduce C's opiate use. We also found that arguably the practice should have provided C with a written warning prior to the first decision to remove them from the practice list. When C had appealed against this decision, however, the practice had reviewed it and agreed to reinstate C subject to commitments about their behaviour. C's second removal had been due to the practice's view that the agreements reached with C had been breached. The practice were entitled to reach this decision and had acted reasonably. Therefore, we did not uphold the complaint.

Summary

C's adult child (A) had anxiety and a functional neurological illness (a condition in which patients experience neurological symptoms such as weakness, movement disorders, sensory symptoms and blackouts). One morning A was found to be anxious and unwell. A's other parent (B) thought it appeared different to A's previous episodes and called the GP who visited A at home.

The GP believed that A should be admitted to hospital and called 999. An ambulance crew attended the scene. There was some discussion between the GP and the hospital about which department A should be admitted to; the Mental Health Unit or the Clinical Assessment Unit. The ambulance crew transported A to hospital where they were quickly assessed and taken to the Intensive Care Unit. A died later that day.

C complained that the Scottish Ambulance Service (SAS) crew did not take A's observations, failed to follow normal protocols and failed to transfer A to the Clinical Assessment Unit straight away.

We took independent advice from a paramedic. We found that the ambulance crew attended promptly and appropriately transferred A to hospital. However, during their time at A's address they did not carry out or document a thorough patient assessment. There were multiple assessment tools (F.A.S.T; blood oxygen saturation levels) which could have been used and were not. When A's breathing rate was abnormally high, further action was not taken as it should have been.

We found that the SAS had not responded to the complaint reasonably and failed to clearly identify errors and what would be done to remedy them going forward. We, therefore, 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:

• Share the findings of this investigation with the ambulance crew and those involved in the reflective learning exercise.

In relation to complaints handling, we recommended:

• SAS should provide as full an explanation as possible in complaint responses as to what mistakes may have occurred (where appropriate) and why they occurred in this case, in order to allow complainants a better understanding of what happened.

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 on behalf of their parent (A) after A was unwell and a GP made a home visit to assess them. The GP called for an ambulance for a 'within the hour' response. The ambulance service called back later and spoke with C to advise that the ambulance was delayed and would attend as soon as possible. C later called 999 and advised that A's condition had deteriorated. This resulted in a higher priority ambulance being assigned.

C complained to the ambulance service about the failure to respond to the requests for an ambulance. In response, the ambulance service acknowledged they failed to meet the initial one-hour response requested, but explained that one-hour ambulance responses are not automatically upgraded. They said that in these circumstances they call back to explain the delay, ask if there is a change in the patient's condition and advise patients to call 999 if there is a change.

C complained to our office that the ambulance service had failed to take account of A's diagnosis provided by the GP, and had therefore not attributed the correct level of priority to the response. C also considered that there was no attempt by the ambulance service to undertake clinical triage of A, resulting in the response level not being upgraded as it should have been. C was unhappy with the investigation and response to their complaint and believed the ambulance service's response to the complaint was not plausible.

We found that whilst there was a significant delay in the ambulance attending to A, this was attributable not to failings on the part of the ambulance service in prioritising the request for an ambulance, but on the lack of available resources at the time.

However, we found that during the welfare call back, the ambulance service should have sought to clarify whether C considered A's condition had deteriorated before continuing with the call. On this basis, we upheld the complaint with respect to unreasonably failing to respond to the request for an ambulance. With respect to the complaint about the complaints investigation, we found the complaints investigation and response was reasonable and did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to confirm whether or not A's condition had worsened before continuing with the call. 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:

• In circumstances where a call handler calls a patient, in line with the Urgent Welfare Call Back Process, they should make reasonable efforts to confirm whether or not the patient's condition has worsened. Where a call handler is unable to obtain clarification as to whether the patient's condition has worsened, the call handler should process the call through the MPDS system in line with the normal emergency call handling 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.