Health

Summary

A few hours after a surgical procedure, C underwent a second operation due to an internal haemorrhage (a loss of blood from a blood vessel that collects inside the body). Following the second operation, C complained to the board about the documenting of their operations, the estimation of their blood loss, communication with their spouse and colleagues, the removal of the patient controlled analgesia (PCA, a method of allowing a person in pain to administer their own pain relief) which was installed following the operations, and that a follow-up appointment was not provided in the timescale they had been advised.

The board's response was that the operations had been reasonably documented, except the detail of one of the units of blood transfused to C, and that the estimation of blood loss and the removal of PCA had been reasonable. The board accepted that they had not communicated with C's spouse and colleagues as C had wished, and that C had not been given realistic information about the likely timescale for a follow-up appointment.

C was dissatisfied with the responses they received and raised their complaints with this office.

We took independent advice from an obstetrician and gynaecologist (a doctor who specialises in pregnancy, childbirth and the female reproductive system).

Although the date and time of the transfusion of the second unit of blood to C during their second operation was omitted, we found that, overall, the board reasonably documented events relating to C's operations. We also found that the board's underestimation of C's blood loss was less critical than vigilance of their condition, observations and blood count. We found that the removal of C's PCA was in line with relevant guidance and that it was reasonable that C was not provided with a follow-up appointment within six weeks given the circumstances. We did not uphold these aspects of C's complaint.

In relation to communication, we found that C's wishes for communication with their spouse and colleagues had not been observed. We upheld this aspect of C's complaint. However, we did not make any recommendations given the action already taken by the board.

Summary

C attended A&E at Glasgow Royal Infirmary with acute pain in their spine; they were admitted in the early hours of the morning and discharged the same day. During their admission, C underwent a hip x-ray scan.

C complained that the care and treatment they received during their visit was not of a reasonable standard. C found their experience to be traumatic and states that it had a lasting emotional impact on them. C had several concerns about their experience; in particular, their pain management and the board's radiology findings.

We took independent advice from an appropriately qualified adviser. We found that the board's approach to pain management was appropriate but felt that it would have been good practice for the board to document C's pain score and actions taken as a result of that score – this was provided as feedback to the board. We also found that C's x-ray was appropriately assessed and concluded that the management of C's radiology (analysis of medical imaging of the body) findings was reasonable.

We considered that the care and treatment offered to C when they attended hospital was reasonable and we did not uphold this complaint.

Summary

C complained about the care and treatment provided to their parent (A) at Queen Elizabeth University Hospital. A was admitted to hospital for an operation, which required a long period of rehabilitation. A's condition began to deteriorate after the operation and they died a few weeks later. C complained that clinical failings relating to hydration, record-keeping and communication were contributing factors to A's deterioration and death. C was also concerned about the way clinicians communicated with them.

We took independent advice from two advisers: a nurse specialist in critical care and respiratory and a consultant in acute medicine. We found that there were unreasonable failings in nursing care including record-keeping, which had an adverse effect on the management of A's hydration, and that the lack of fluid management had a distressing impact on A and their family at the end of their life. However, these failings did not substantially impact on A's chance of survival or death. We also found that opportunities were missed to inform A's family of their condition which meant that they were unprepared for A's deterioration and death. We upheld all of C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

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

• Ensure a reasonable standard of communication which meets the needs of patients and their families.
• Ensure a reasonable standard of fluid management.
• Ensure patients' hydration is managed reasonably.

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 the treatment which they received when they attended the out of hours service (OOHS) at Aberdeen Royal Infirmary. C said that they had already reported problems with back pain and loss of feeling to their GP practice. However, the OOHS doctor who attended to C did not conduct examinations or arrange investigations such as a scan, and told C to see their GP the following day. C was taken by ambulance to hospital the following day and, after a CT scan, they were diagnosed as having cauda equina syndrome. C felt that the doctor at the OOHS should have completed a more thorough examination and that the correct diagnosis would have been reached sooner and would not have had such a drastic effect on their health.

We took independent advice from a GP. We found that that although the OOHS doctor obtained a good history from C and conducted a reasonable examination, they failed to action C's progressive neurological symptoms and new onset bladder problems. These required referral for an orthopaedic (conditions involving the musculoskeletal system) opinion or further investigations that day. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure of the OOHS GP to fully consider the red flag symptoms presented which indicated the possibility of developing cauda equina syndrome. 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 OOHS GP should ensure that when red flag signs are evident when a patient presents that they conduct a full examination and consider whether an urgent referral to a hospital specialist is appropriate. In addition, the OOHS GP should discuss this complaint at their annual appraisal.

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 practice about the treatment that they received when they contacted the practice with back problems. C spoke to a GP and an advanced nurse practitioner (ANP) by telephone during that period due to the COVID-19 restrictions and C was advised to make further contact should their situation worsen. C was taken by ambulance to hospital and after a CT scan was diagnosed as having cauda equine syndrome (a disorder that affects the nerves). C felt that the GP and the ANP should have seen them in person for an examination and that had this been the case, the correct diagnosis of cauda equine syndrome would have been reached sooner and would not have had such a drastic effect on their health.

We took independent advice from a GP and an ANP. We found that C had a previous history of back problems over a number of years which were felt to be sciatica (back and leg pain caused by irritation or compression of the sciatic nerve) and musculo-skeletal in nature and that it was not unreasonable to attribute C's reported symptoms to those conditions. However, when C attended hospital their condition had deteriorated and they had reported new symptoms which were red flag signs of cauda equine syndrome. We did not uphold the complaint.

Summary

C complained to us, on behalf of A, that the board failed to appropriately diagnose and treat A during their attendances at Aberdeen Royal Infirmary. A had chronic obstructive pulmonary disease (COPD, a disease of the lungs in which the airways become narrowed) and had also previously been diagnosed with probable left sided lung cancer several years earlier. At that time, it was agreed that A would receive high dose palliative radiotherapy (a treatment using high-energy radiation).

Over a period of eight months, A was admitted to hospital nine times. The first five of these admissions were to a respiratory ward and the last four to a general medical ward. They were treated for worsening of COPD and increasing frailty. A had a fall during one of the admissions, but was subsequently discharged home. C said that at that time, A was not fit for discharge as they required to be readmitted again a few days later when they were told that they had terminal cancer. A's condition subsequently deteriorated further and they died the following month.

We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly). Although the board had acknowledged that the clinical records did not show that A's underlying diagnosis of cancer was discussed with them in appointments in the final two years of their life, we found that there was no evidence that the board failed to properly diagnose and treat A during the relevant hospital admissions. We did not uphold this complaint.

C also complained that the board failed to communicate appropriately with A during this period, despite them having power of attorney for A. We found that A's care and treatment were discussed reasonably with both C and A and we therefore, did not uphold this complaint.

C complained that the board failed to handle A's complaint in line with their obligations. We were satisfied that the board dealt with A's complaint in accordance with their complaints handling policy and this complaint was not upheld.

Finally, C complained that the board unreasonably failed to certify correctly the cause of A's death. Whilst the initial death certificate was not incorrect, it was revised to give more clarity. Although we found that it would have been better for C to have been provided with a more detailed explanation for the required change in the first place, it is not unusual for death certificates to be revised in these circumstances. We did not uphold this complaint.

Summary

C, a support and advocacy worker, complained on behalf of their client (B) about the care and treatment their child (A) received in the early months of their life. A was born prematurely, suffered a number of medical problems following their birth and died a few years later. A was initially cared for in Aberdeen Maternity Hospital's neonatal unit. A was transferred for treatment in the High Dependency Unit (HDU) at Royal Aberdeen Children's Hospital. C asked us to investigate the standard of care and treatment that A received at Royal Aberdeen Children's Hospital. B said that A suffered a number of desaturation episodes which caused A to turn blue. They attributed this to staff being slow to react. A's feeds were increased upon admission to Royal Aberdeen Children's Hospital. B said that A's health began to deteriorate from this point. B said that A should have remained in Aberdeen Maternity Hospital's neonatal unit given A's weight at five months was still below that of many neonates, or else transferred to another neonatal unit elsewhere in Scotland. They complained that, whilst A was in Royal Aberdeen Children's Hospital, the level of supervision was insufficient, particularly over weekends.

We took independent advice from a consultant paediatrician and a paediatric nurse. We found that, while A's condition was complex, there was nothing to suggest that moving A to the HDU at Royal Aberdeen Children's Hospital resulted in a drop in the level of care and support available. We also found that the overall approach to managing and monitoring A's weight was reasonable. We did not uphold these aspects of C's complaint.

In relation to nursing supervision, we found that nursing staff reasonably monitored A throughout their time in the HDU, maintaining detailed and thorough records and appropriately escalating any issues identified to the medical team. We did not uphold this aspect of C's complaint.

In relation to medical supervision, while the nursing staff appropriately monitored A's condition and escalated A's management to medical colleagues when changes were observed, we found that these were not acted upon within a reasonable time in every case. On one occasion no medical staff attended for four hours following escalation by nursing staff. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's parents for the unreasonable delay in fulfilling a request for a medical review of A.The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• The board should have a system in place to alert a more senior member of the medical team to attend when requests for medical reviews cannot be fulfilled by the relevant medical staff within a reasonable timescale.

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, a support and advocacy worker, complained on behalf of their client (A) and their partner. A and their partner's child (B) was born at 30 weeks gestation. B was severely disabled and died when they were two years old. B's parents had been told that B had suffered hypoxic ischaemic encephalopathy (HIE, a form of brain injury that occurs when the brain does not receive sufficient oxygen) due to a lack of oxygen in the period prior to their birth. Despite HIE being detailed in B's records as a diagnosis, the board contended that B did not have this condition when responding to B's parents' formal complaint.

B's parents considered there to have been an unreasonable delay to A receiving an emergency section following their urgent referral from Peterhead Hospital to Aberdeen Maternity Hospital. C asked us to investigate whether the level of care that A received from the board fell below a reasonable standard and whether any deficiencies in the standard of care may have contributed to B's health problems.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in pregnancy, childbirth and the female reproductive system) and a senior midwife. We found that A was appropriately given a cardiotacograph (CTG, a way of recording the fetal heartbeat and the uterine contractions during pregnancy) at Peterhead Hospital on the first date complained of, and was appropriately transferred to Aberdeen Maternity Hospital. In relation to the second date complained of, we found that A was again appropriately transferred to Aberdeen Maternity Hospital, although we noted that a CTG was inappropriately stopped at one time, once A had been transferred. However, we also found that transfer to the labour ward took place at an appropriate time and that the decision to move A to theatre and carry out an emergency caesarean section was taken at an appropriate time. The advice we were given did not indicate a connection between the results of tests undertaken at this time and any health problems that B suffered following their birth. We considered that the board's overall management of A had been reasonable and did not uphold the complaint. However, we provided feedback to the board regarding record-keeping.

Summary

C complained about the medical and nursing care that their late parent (A) received at Forth Valley Royal Hospital. Regarding A's medical care and treatment, we took independent advice from a general and colorectal (bowel) surgeon. We found that reasonable action was taken to assess A's cardiac murmur (unusual sounds made by turbulent blood in or near the heart). However, following the exclusion of malignancy or an acute surgical issue, it would have been reasonable to involve a more specialised team involved in the care of the aged. It was reasonable that the board made a referral to the Aging and Health department in the circumstances. However, we found that it was unreasonable that this specialist review did not take place (which may have provided a different perspective on A's symptoms). We noted that the board had already acknowledged and apologised for this failure and had described that the board took reasonable action to address this. We upheld this aspect of C's complaint and requested evidence of the action the board had taken.

Regarding A's nursing care, we took independent advice from a nursing adviser. We found that the assessment and control of A's pain was reasonable and that there was evidence that A's pain level was regularly assessed and that a review of their nursing notes did not indicate that A was in pain for most of their in-patient stay. However, we also found that it was unreasonable that A's fluid intake and output were not monitored using a food balance monitoring chart given their overall condition, cognitive issues, feeling of nausea, low blood pressure, swollen legs and that they had been receiving IV fluids. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not monitoring A's fluid intake and output appropriately using a fluid balance monitoring 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:

• Fluid balance monitoring charts should be used to monitor fluid intake and output, particularly where the patient has cognitive issues, feelings of nausea, low blood pressure, swollen legs or have been receiving IV fluids.

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 has Crohn's disease (a condition where parts of the digestive system become inflamed) and had received various treatments, including two previous surgical procedures to remove lengths of small bowel. C attended Forth Valley Royal Hospital with abdominal pain. A CT scan showed inflammation of the ileum (a portion of the small intestine) at the site of the joint that had been created by the previous bowel resection (partial surgical removal of an organ). The decision was made to operate as an elective procedure (surgery that is scheduled in advance because it does not involve a medical emergency). The operating surgeon considered the length of small bowel identified on previous imaging was not causing an obstruction, and decided not to remove it. C continued to experience difficulties following the surgery, including a number of further hospital admissions.

C complained that the care and treatment they received from the board was unreasonable. We took independent advice from a general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We found that, while the level of investigations carried out were reasonable, a midline incision (a vertical cut made in the abdomen to allow access for a medical procedure) should have been performed in C's case. We noted that if a midline incision was employed, then it is likely that the resection would have been carried out as planned. We were also critical of the level of documentation provided by the board. As a result, we upheld this element of the complaint.

C further complained that the communication they received from the board was unreasonable. We found that there was no evidence to show that appropriate explanations were given to C following the surgery, and no evidence to demonstrate the board's clinicians effectively communicated with C about their condition. As a result, we upheld this element of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings this investigation has identified. 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:

• Clinicians must communicate effectively with patients, and make adequate records of these communications.
• The board should have appropriate pathways in place for the management of Crohn's disease, to ensure surgery to address this condition is carried out appropriately.

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.