Health

Summary

C underwent sequential cataract surgery (a surgical procedure to replace the eye lens with an artificial one when the cataract makes the vision cloudy, specifically, in this instance, monofocal lens implantation). C complained that the board had failed to communicate reasonably with them prior to the cataract surgery, including that the risks and benefits were not explained to them and that their concerns following first cataract surgery were not taken seriously.

We sought independent advice from an ophthalmologist adviser (specialist in the branch of medicine that deals with the anatomy, physiology and diseases of the eye). We found that there was no record that C was given information about the risks and benefits of the surgery. The lack of written information about the risks and benefits of the procedure was unreasonable. We noted that this was contrary to the General Medical Council's guidance to keep an accurate record of the exchange of information. We also found that there was no record of what was discussed with C following the first cataract procedure. As there is no written record, we were unable to determine what was discussed with C when they raised concerns.

In light of the above, we considered that there was a failure to communicate reasonably with C prior to the cataract surgery and we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not giving them information about the risks and benefits of monofocal lens implantation and for not recording what was discussed with them following the first cataract procedure. 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:

• Discussions with patients following cataract procedures should be clearly recorded.
• Patients should be advised of all material risks and benefits of cataract procedures and the discussion should be clearly recorded, in accordance with relevant standards and 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 that they received from the board when they were admitted to Hairmyres Hospital with a psychotic episode. C raised a number of issues, including that the nursing and clinical staff at the hospital failed to adequately explore the possible link between the unpleasant/harmful physical symptoms C was experiencing, which they said they reported on a daily basis, and the medication they were given.

We took independent advice from a mental health nurse and a consultant psychiatrist. We found that, generally speaking, staff responded appropriately to C's complaints; observations, examinations, investigations and onward referrals were appropriately initiated when C voiced concerns. However, there was a clear failure to carry out daily monitoring of C's pulse and blood pressure in a consistent and reasonable manner, and record the readings and C's resulting National Early Warning System (NEWS, a pro forma for recording patients' physical observations that generates a score to alert staff to potential changes in a patient's physical condition) score on the NEWS chart. We noted that the failings in recording of C's pulse and blood pressure on the NEWS chart and the resulting NEWS score was a potential contributory factor to C developing hypotension (low blood pressure). Interventions to manage this, such as the withdrawal of Olanzapine (an antipsychotic drug), were delayed at a time when this would have been beneficial in alerting the clinical team to physical issues experienced by C. This resulted in C experiencing short term discomfort and distress from hypotension. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to consistently monitor C's pulse and blood pressure and record these, along with C's NEWS score, on the NEWS chart. 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' vital signs observations should be conducted in line with agreed frequency and the readings and resulting NEWS scores recorded on the NEWS charts.

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 failure to accurately diagnose and treat their parent (A)'s pancreatic cancer. A was being investigated by Raigmore Hospital in the months prior to their death. C complained that too many invasive tests were carried out and an accurate diagnosis was not established.

We took independent medical advice from a consultant surgeon, who noted that A had an advanced pancreatic cancer which can be difficult to diagnose. We considered that repetition of invasive tests was reasonably required in order to pursue a diagnosis. We noted, however, that A's lung abnormalities were discussed by a lung multidisciplinary team (MDT), but an upper gastrointestinal MDT was not involved despite the fact the suspicion of pancreatic cancer could not be ruled out. We fed this back to the board. However, overall, we considered that there was a comprehensive attempt to obtain a diagnosis. On balance, we did not uphold this complaint.

C also complained about a failure to communicate clearly with A and the family regarding the diagnosis. They said that they were never made aware of the suspected cancer diagnosis, despite this having been documented throughout the records. We found no evidence to support that timely and meaningful discussions took place with A and their family. A consented to multiple invasive tests without being made aware that suspected cancer was being investigated. We considered that the risks and benefits of these tests should have been clearly discussed with A, in order for them to have made a fully informed decision as to whether to proceed with them. In the circumstances, we upheld this complaint. We also noted that the board's response to C's complaint did not provide a sufficient explanation of the extent of the tests carried out.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that timely and meaningful discussions did not take place with A and the family to inform them of the suspected cancer diagnosis and make them aware of the purpose, potential benefits and risks of invasive investigations; and that the complaint response did not comprehensively address the specific concerns raised. The apology should meet the standards set out in the SPSO guidelines on apology: www.spso.org.uk/information-leaflets.

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

• Patients should be provided with all the information they need to be able to make informed decisions about their care. This should include information about their diagnosis; any uncertainties in this regard; and a clear explanation of the purpose of any proposed investigations or treatment, including potential benefits and material risks. This should be adequately recorded in the case notes to evidence that meaningful dialogue has taken place.

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 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.