Health

Summary

C's parent (A) had complained for a number of years about pain in their legs. They considered that their concerns had been dismissed and that they weren't reasonably responded to. A later required a stent and an angioplasty (a procedure to widen narrowed or obstructed arteries or veins) after they experienced a blockage of an artery in their leg. While initially successful, the stent then blocked, leading to a second procedure. A later had their leg amputated. C considers this could have been avoided with earlier treatment.

C complained that the board failed to reasonably respond to issues regarding A's feet and legs. We took independent advice from a vascular adviser (treats disorders of the circulatory system). We found that prior to the severe blockage experienced by A, the actions taken by the board in response to their symptoms of pain and numbness were reasonable. We found that these symptoms were unrelated to the sudden onset situation where A had blockage of the external iliac vessel (relating to the large broad bone forming the upper part of each half of the pelvis or the nearby regions of the lower body) on the left side, and we found that the response to this blockage was reasonable. When the stent then became blocked, we found that the response to this was also reasonable. However, communication with A and their family could have been better in terms of explaining A's symptoms, how A was followed up after the procedure and the possibility that the initial stent could fail.

While there were some communication issues and there should have been further follow-up after the first stent was placed, we found that the overall the treatment provided by the board was reasonable. Therefore, we did not uphold this complaint.

Summary

C complained about the length of time they waited for gallbladder surgery. They had two emergency admissions to hospital without surgery being carried out and had been placed on the waiting list for surgery after their second admission. C said that they were left in chronic and excruciating pain and considered the surgery should have been carried out on an emergency basis. They considered the length of time that they were waiting was unreasonable. As a result, C had the surgery carried out privately.

The board said that it was reasonable to postpone surgery each time C was admitted to hospital because their gallbladder had been inflamed. C was seen and allocated to the surgery waiting list. C's surgery would have been carried out within current NHS waiting times.

We took independent advice from a colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We found that C should have been regarded as a high priority case given their symptoms had led to two emergency admissions and, after each admission, they should have been offered an early appointment for surgery once the inflammation settled. Instead, due to an administrative error, an initial follow-up appointment was not offered after the first admission. After the second admission, C was added to the waiting list with no indication as to when their surgery would take place.

We found that the board had failed to arrange C's gallbladder surgery within a reasonable timeframe and, therefore, we upheld C's complaint. We took into account that the cost of the private treatment was partly due to the board's failings and also partly due to a private decision by C. In the specific circumstances, we recommended that C be reimbursed to the extent which the surgery would have cost the board.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable delay in the time that they waited for gallbladder surgery and not communicating more clearly with them about this. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Reimburse C for the amount that the operation would have cost the board. The payment should be made by the date indicated; if payment is not made by that date, interest should be paid at the standard interest rate applied by the courts from that date to the date of payment.

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

• Management of emergency admissions for patients with cholecystitis should be reviewed so that treatment for the diagnosis and management of gallstone disease is based on National Institute for Health and Care Excellence (NICE) guidance, in particular, when an early cholecystectomy should be considered. A clear treatment path should be in place for patients whose surgery must be delayed because of acute clinical factors (such as a chest infection). For patients whose surgery must be delayed because of acute clinical factors, there should be clear communication with the patient as to when they can expect to have their surgery.

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 in Accident & Emergency (A&E) following an accident. In particular, C was concerned that they were not kept in hospital for at least 24 hours following the accident, that they did not receive emergency surgery and that their x-rays were not looked at properly to identify the full extent of their injuries.

We took independent advice from an emergency medical adviser and a radiology adviser (analyses images of the body). We found that it was appropriate to manage C's injuries conservatively and that there was not a need for emergency surgery, that it was appropriate to discharge C with a plan for follow-up with the orthopaedic (conditions involving the musculoskeletal system) surgeons and that the A&E staff correctly identified C's injuries from the x-rays. We, therefore, did not uphold C's complaint regarding the care received in A&E.

C also complained about the orthopaedic care and treatment that they received. We took independent advice from a consultant orthopaedic surgeon and a radiology adviser. We found that assessments and examinations carried out by the orthopaedic department were reasonable. We, therefore, did not uphold C's complaint in this regard.

Summary

C complained on behalf of their client (B) in relation to the care and treatment provided to B's partner (A) whilst A was a patient at Western Isles Hospital.

C complained that the board failed to provide A with reasonable care and treatment whilst A was a patient in the hospital. In particular, C is concerned that venous thromboembolism (referring to blood clots in the veins) testing (VTE) was not carried out and that there was a delay in coagulation screening (screening laboratory tests which allows an initial broad categorization of haemostatic problems). C considered that if reasonable care and treatment had been provided, A may not have died. C also believed that the board did not reasonably respond to their complaint about this matter.

The board noted that whilst a VTE assessment was not performed, and there was a delay in coagulation screening, this would not have altered A's clinical management or have changed the outcome, as A was extremely ill. The board stated that they considered they had reasonably responded to C's complaint.

We took independent advice from an appropriately qualified adviser who determined that although the overall care and treatment offered to A was reasonable, there was learning for the board.

We found that the board had failed to conduct a VTE assessment and had failed to administer a prophylactic dose of heparin on the evening of A's admission which was unreasonable. However, even if a VTE assessment had been carried out, and a prophylactic dose of heparin given, it would not have altered the clinical outcome in this case. We also found that the board's reason for a delay in coagulation screening was reasonable. We, therefore, did not uphold this complaint. Furthermore, we found that the board had reasonably responded to C's complaint. We identified learning for the board which was provided by way of feedback.

Summary

C brought a complaint to us about the gynaecology (medicine of the female genital tract and its disorders) care and treatment they received when they attended Ninewells Hospital. In particular, C complained that they suffered complications from the surgery they underwent and felt that a number of things had gone wrong due to incorrect procedures. C explained that they felt that they were not listened to, nor were they cared for properly or treated with dignity and respect.

We took independent advice from a consultant gynaecologist. We found that while there was some learning for the board in relation to the saving of ultrasound documentation (pictures or hard drive images) and advising C to check for coil threads, the overall care and treatment given to C was reasonable and the complications which arose in this case were recognised complications. We also found that C had been fully and appropriately consented for these. We did not uphold this aspect of C's complaint.

C also complained about the way the board handled their complaint. We found that the board have already acknowledged and apologised for failings identified and said that changes had been made to individuals' practice and to some systems. In the circumstances, while we upheld the complaint, we had no recommendations to make.

Summary

C had been seeking treatment for urinary incontinence but said they experienced significant delays and were asked to attend unnecessary appointments. C also raised concerns about the standard of communication and treatment decisions during this period. C told us that they had been unable to work as a result of the failings.

We took independent advice from a consultant urological surgeon (a doctor who specialises in the male and female urinary tract, and the male reproductive organs). We found that when C was referred to gynaecology (specialists in the female reproductive system), no surgical options had been available for the treatment of urinary incontinence in the health board area for a number of years and that this was not explained to C until 21 months after referral, despite C having seen at least two gynaecologists by that time. We also found a lack of organisation in terms of staff identifying and communicating the treatment options available to C and putting a treatment plan in place from an early stage. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide them with a reasonable standard of care and treatment. The apology should meet the standards set out in theSPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Ensure communication by healthcare professionals is of a reasonable standard and meets the relevant guidelines.

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 Scottish Ambulance Service made the decision that their headache was due to a less serious cause (rather than the serious diagnosis that was later identified), which did not require urgent assessment at A&E. C was also concerned that they were taken to the out-of-hours GP rather than to A&E.

We found that the there was no evidence in the records that the ambulance crew made any decisions about the cause of C's headache. The records indicate that the crew considered the symptoms C was experiencing required hospital assessment.

The records also indicated that a handover was given to a nurse within A&E at the hospital and that the nurse was advised that C had a two day history of headaches. It appeared that the decision to transfer C to the out-of-hours service was made by staff within the A&E department, rather than by the ambulance crew.

We did not uphold C's complaint.

Summary

C complained about the actions of Scottish Ambulance Service (SAS) staff when they attended to their adult child (A) following an epileptic seizure (bursts of electrical activity in the brain that temporarily affect how it works and can cause a wide range of symptoms). A was moved onto a chair to be taken out of the house to an ambulance. When A arrived at hospital they were found to have broken vertebrae (individual bones that interlock with each other to form the spinal column). C complained about the manner in which staff had transferred A and about their clinical assessment of A.

SAS said that staff carried out a risk assessment on how to get A to the ambulance; the moving and handling skills applied were based on the clinical assessment of A and access difficulties at the scene.

We took independent advice from a paramedic. We found that the history assessment and energy involved with A's mechanism of injury made it extremely unlikely to cause a significant spinal injury. Given the age and medical history obtained, there were no risk factors which would lead the paramedic to suspect spinal injury. This, coupled with the restricted space within which they were working, made the use of a carry chair a reasonable means of transferring the patient. Therefore, we did not uphold this complaint.

In relation to the clinical assessment, we found that while A complained of back pain, this was not considered to be a spinal injury. We considered the assessment and management were reasonable for a patient suffering a 'seizure now stopped'. We noted that the paramedic used the finding of motor, sensation and circulation of lower limbs in their risk assessment to help rule out/in spinal injury. Given the history and assessment findings, we considered the care provided was reasonable. As such, we did not uphold this complaint.

We noted there had been complaints handling issues, but SAS had taken appropriate steps to address this and had apologised to C.

Summary

C complained that the board failed to appropriately triage their relative (A) when A self-presented to the Medical Assessment Unit (MAU) at Western General Hospital feeling unwell. A spoke with the receptionist who took details of their symptoms and, having discussed A's symptoms with clinical staff, the receptionist advised A that they should contact NHS 24.

A left the hospital and contacted NHS 24 who advised A to take paracetamol for the pain. A was taken to another hospital in the early hours of the next day and had an emergency operation for a ruptured appendix.

In response to the complaint, the board explained that the receptionist acted in line with their normal processes. C was not satisfied with the response provided and brought the complaint to our office.

We found that the board were unable to evidence that A was reviewed by a triage nurse or doctor in person as per their protocol. Given there was no evidence that the appropriate protocol was followed, we upheld the complaint. In addition, having reviewed the handling of C's original complaint, we concluded that the board failed to appropriately investigate and respond to C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to follow the protocol when they attended the hospital and for failing to take appropriate records of the assessment and triage. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for failing to appropriately investigate and respond to their complaint. The apology should meet the standards set out inthe 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, a support and advocacy worker, complained on behalf of their client (A) about the board's failure to share confidential patient information with A. C said that information was unreasonably withheld and should have been shared as their safety was at risk. C also complained that the board wrongly treated A's complaint as a 'concern' and they took an unreasonable length of time to respond.

The board said that they were not in a position to share the information A had requested, however they recognised there was some learning for the clinical team and they took steps to address this. The board also said they did not treat C's initial email as a complaint as it clearly stated A wanted to “discuss their experience and concerns”. The board recognised their written response was not issued within a reasonable timescale.

We took independent advice from a mental health nurse. We found that it would have likely been reasonable and legally justifiable for some of the information A requested to be shared with them. We identified that staff were not fully familiar with the national guidance on consent, confidentiality and information sharing. We upheld the complaint.

In relation to complaint handling, we concluded that it was reasonable to treat A's initial email as a concern and a request for a meeting. However, matters became confused when the board's written response following the meeting included SPSO referral details, which inferred it was a complaint response. When C submitted a formal complaint, we noted that the board did not meet the required timescales. On that basis, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to consider whether the disclosure to A of confidential patient information was justifiable. 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.