Health

Summary

C complained about the care and treatment provided to their parent (A). A was reviewed in the A&E department of a GP led community hospital with epigastric pain (pain or discomfort right below the ribs in the area of the upper abdomen). A felt that the pain was coming from their gallbladder. Tests for a urinary tract infection (UTI) were carried out and A was admitted to a ward for fluids and treatment with an antibiotic. A few days later, the decision was taken to transfer A to another hospital. Further tests carried out there revealed A's gallbladder had perforated causing an abscess on their liver. They were then subsequently diagnosed with gallbladder cancer.

C complained about the care and treatment provided to A at the community hospital. The board said that gallbladder pain usually radiates to the shoulder which was why this was considered unlikely in A's case. A was stable but diagnosis was unclear so they were admitted for observation and antibiotics for a UTI, which had been confirmed on testing.

We took independent advice from an appropriately qualified clinical adviser. We found that A did not have specific clinical features of a UTI and urinalysis was not convincing for a bacterial infection. The clinical presentation of nausea, sweating and epigastric pain accompanied by the finding of the right upper quadrant tenderness was more in keeping with gallbladder pain and infection. We also noted that once A's abnormal blood results were known, the decision should have been taken on that same day (the day following admission) to consider transferring A to secondary care, because their clinical condition and abnormal blood results suggested something that could not be managed properly or adequately in a GP led community hospital. We also found that A was given too much IV fluid during their admission. Given A's known history of heart failure, the administering of fluid should have been regularly reviewed. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failure to acknowledge that A did not have specific clinical features of a UTI and recognising that urinalysis did not indicate bacterial infection; failure to appropriately consider gallbladder pain and infection; administering too much IV fluid during A's admission and for not reviewing this regularly; failure to take A's abnormal blood result seriously; and failing to appropriately consider transferring A to an acute hospital once their blood results were known, given their clinical condition. 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 implement clear guidance within the GP led community hospital to make clear who can be admitted along with clarity on the level of care that can be provided. The guidance should include criteria under which transfer to an acute hospital should be considered.
• The board should share this decision with the doctors involved in a supportive manner, and ask that they reflect on A's case.

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 treatment for abnormal cervical changes. Around nine years later, a cervical smear test showed borderline changes and they were scheduled for follow-up six months later. Their next smear showed changes requiring investigation and C was seen for a gynaecology (relating to the female reproductive system) scan, at which the consultant also carried out a colposcopy (a simple procedure used to look at the cervix). Everything appeared normal but taking C's history into account they were followed up six months later. The follow-up smear showed severe dyskaryosis (change of appearance in cells that cover the surface of the cervix), prompting an urgent referral to colposcopy. C was seen six weeks later and was later informed that they had adenocarcinoma (a type of cancer), and required a radical hysterectomy (surgery to remove the uterus) and adjuvant chemoradiation (additional cancer treatment given after the primary treatment to lower the risk that the cancer will come back).

C complained that their history of three abnormal smears in the ten preceding years should have led to a referral to colposcopy after their first abnormal smear. C believes that if they had been referred to colposcopy and had a biopsy taken earlier, the need for adjuvant chemoradiation could have been avoided. They complained that the board failed to take account their medical history when considering whether to refer to colposcopy or take a biopsy. C also complained about the board dropping them from cancer tracking, and about the delay between biopsy and treatment.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in pregnancy, childbirth and the female reproductive system). We found that referral to colposcopy was not indicated earlier, explaining that the first smear was the first abnormal smear in a new episode and the recommendation for repeat in six months was in keeping with the cervical screening programme. We also found that C's examination following the second smear was satisfactory and it was reasonable not to carry out a biopsy at that time. We did not uphold these aspects of C's complaint.

In relation to the cancer tracking, the board accepted that C should not have been dropped as, given C's pathology results, they clearly required further treatment. Tracking is carried out to ensure patients are followed up timeously and within national targets. We considered that it was unreasonable to drop C from tracking, and we therefore upheld this aspect of C's complaint.

Finally, we considered that the delay in seeing C for colposcopy following their severely dyskaryotic smear, and further delay between diagnosis and treatment, was unreasonable. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in commencing treatment, recognising the impact this matter had on 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 meet national targets for the first appointment following referral with an abnormal smear, and following a positive cancer diagnosis.

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 board's significant clinical incident investigation and complaint investigation unreasonably failed to identify all the failings regarding the care and treatment provided to their spouse (A). We took independent advice from a general surgeon. We found that the Significant Clinical Incident Review did not identify that:

it was unreasonable that no clinical observations or clinical review took place when A developed an acute onset of pain on the surgical ward;

it was unreasonable that A's case was not discussed earlier with a consultant on the surgical ward; and

it was unreasonable that a request for an urgent CT scan was not made earlier.

We upheld C's complaint in this regard and made recommendations to the board.

C also complained that the board failed to take reasonable action to address the failings identified following the significant clinical incident investigation and complaint investigation. We took independent advice from a nursing adviser with experience of working in and managing an Intensive Care Unit. We found that the board had taken reasonable action to address these failings. While we fully appreciated that actions taken by the board will not change A and C's experience, we were satisfied that learning and improvement had taken place which should prevent the same situations from arising again. We did not uphold C's complaint in this area.

We also considered how the board had handled C's complaint. We found that the board did not provide a revised timescale for when C could expect to receive the response to their complaint and made recommendations to the board in this regard.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to carry out a clinical observations or a clinical review when A developed an acute onset of pain on the surgical ward, failing to discuss A's case with a consultant earlier on the surgical ward, failing to request an urgent CT scan at the relevant time, and not providing a revised timescale for when they could expect to receive a response 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.

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

• Deteriorating patients should be escalated to a senior clinician especially in those with ongoing low blood pressure. Where appropriate in these cases, a senior doctor should carry out a physical examination.
• Patients who have an acute onset of severe pain should be reviewed by a clinician and the findings should be documented.
• Significant Clinical Incident Reviews should be robust and, so far as is possible, identify all failings in clinical care to ensure there is appropriate learning and improvement.
• Urgent CT scans should be requested where a diagnosis of ischaemic bowel is being considered.

In relation to complaints handling, we recommended:

• Where the 20 working day timescale for a response cannot be met, the complainant must be kept updated on the reason for the delay and given a revised timescale for completion.

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 adult child (A). A was admitted to the Royal Alexandra Hospital via A&E after four weeks of diarrhoea and vomiting where they were diagnosed with Crohn's disease (a long-term condition that causes inflammation of the lining of the digestive system). It was suggested for A to have medical treatment with infliximab (a medication used to treat autoimmune disorders) which might prevent the need for surgery. This was prescribed for A and A was discharged to receive the second dose at an out-patient clinic. When A attended the out-patient clinic for the second dose, the hospital would not administer it as A had an existing infection.

A was re-admitted to hospital and a dose of infliximab was given. A was told that as they had not responded to infliximab, the board would perform a sub total colectomy (a surgical procedure to remove all or part of the colon) which would be reversible after 12 months. A had their surgery and a few days later their condition deteriorated and they required emergency surgery. It was found that A had a duodenal peptic ulcer (an open sore inside the lining of the stomach or small intestine) which had burst and caused sepsis (a serious reaction to infection). C complained about the medical and nursing care that A received.

We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines) and a nursing adviser. We found that there was a lack of clarity about whether the first infliximab dose was administered, the second dose was unreasonably delayed, there was miscommunication about A's surgery and concerns about how A's condition was monitored overnight when their condition deteriorated. There also was no evidence that a medical/surgical review had taken place when it should have. Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for unreasonable care and treatment provided to A, communication failures and the lack of clarity about whether key medication was administered. 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 staff are aware of how the error in communication occurred and how to prevent a reoccurrence.
• The board should reinforce the national guidelines 'Professional Guidance on the Administration of Medicines' RPS & RCN Jan 2010 and local policy 'Safe and Secure Handling of Medicines in Wards, Theatres and Departments' NHSGGC 2008 (currently under review).

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). A was diagnosed with oesophageal cancer (tumour in the tube which connects from throat to the stomach) and later underwent chemotherapy and radiotherapy. Over a year later, A had a CT scan but the results were not reported for around three weeks. The CT scan found evidence that the cancer had spread to the liver. It was no longer possible to cure the cancer and A's care became palliative (managing pain or related symptoms, but not treating the underlying disease or condition). A was admitted to the Queen Elizabeth University Hospital where they later died.

C complained that there was an unreasonable delay in reporting and communicating the results of A's scan. We took independent advice from a consultant oncologist (a doctor who specialises in the diagnosis and treatment of cancer). The board had accepted there was a delay in formally reporting the CT scan and acknowledged it was a significant failure to report a life changing progression of disease. We upheld the complaint but as the board had already apologised for this error, we did not make any further recommendations. We also noted that the delay in issuing the report did not change the situation for A as the disease was already advanced.

C complained that the board failed to communicate reasonably with A's family during their admission to hospital. We found that there were annotations about discussions with the family in the records and it was routinely noted when family were present. However, there was little in the notes to show what was said or what individuals' concerns were. Therefore, we upheld this complaint.

C also raised a number of concerns about care provided to A during their admission. We found that there were elements of the care provided to A which were not best practice, some of which the board had already acknowledged in the complaints process. However, there were also many elements of A's treatment which were reasonable. On balance, we did not uphold this complaint.

Recommendations

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

• For staff to have the opportunity to reflect on the findings of this investigation.

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) about the care and treatment A received from the board. A has Parkinson's disease (a condition in which parts of the brain become progressively damaged over many years, causing physical and neurological symptoms). A was admitted to the Queen Elizabeth University Hospital with a suspected clot. Staff thought that A had suffered a stroke and physiotherapy was arranged as part of their recovery. Following an MRI, it was found that some of A's vertebrae (the bones of the spine) were displaced and were compressing the spinal cord. A was transferred to a consultant neurosurgeon (specialist in surgery of the brain or other nerve tissue).

We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly) with a special interest in Parkinson's disease. We noted that A had had Parkinson's disease for 15 years. They had also had surgery to their neck and lumbar stenosis (narrowing of the bone spaces where the nerves leave the spine in the lower back). A was reviewed by the Parkinson's specialist who suggested that a CT brain scan be carried out. This showed a minor change in the brain which could have been consistent with a small stroke. However, a later scan ruled this out. An MRI scan was ordered of the spine and it was following this scan that A's condition was diagnosed.

We noted that A had a complex medical condition and the symptoms they were exhibiting could have come about by a number of different causes. We found that the board worked through reasonable diagnoses and requested appropriate medical imaging. Therefore, we did not uphold the complaint.

Summary

C, an advocate, complained on behalf of their client (B). B's partner (A) was diagnosed and treated for a frozen shoulder (a condition affecting the shoulder, making it painful and stiff with loss of mobility) by the board after attending the emergency department. A's pain and symptoms did not improve so they continued to attend health services. B considered it was unreasonable for A to have been diagnosed with a frozen shoulder based on their level of pain and the board failed to provide reasonable treatment. A's health deteriorated and they were diagnosed with cancer. B said this diagnosis and A's prognosis were not appropriately communicated.

We took independent advice in relation to the complaints.

C complained that the board unreasonably administered a steroid injection to A. We found that A's symptoms were atypical for a frozen shoulder and there were red flag symptoms present. Therefore, the case should have been discussed with the responsible consultant at the clinic and further investigations carried out, prior to a decision on whether the injection should be administered. Therefore, we upheld the complaint.

C also complained that the board failed to diagnose A's cancer in a reasonable timescale. We found that there was a short but unreasonable delay in diagnosing A's cancer. We considered that the actions during most of A's attendances were reasonable. However, they raised concerns regarding no consultant opinion being sought when A attended the emergency department and that there was a missed opportunity to investigate A's atypical symptoms during one of the appointments. We found that there was a lack of clinical ownership for A's case. Therefore, we upheld the complaint.

C also complained the board failed to communicate A's cancer diagnosis in a reasonable manner. There was limited information to consider as the records were not a verbatim account of conversations. We found that there was no evidence to suggest the doctor communicated with A and B in a cold or uncaring manner. Therefore, we did not uphold the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for administering the steroid injection to A and for the delay in diagnosing A with cancer. 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:

• Cases involving multiple specialties should be appropriately managed and atypical signs of frozen shoulder appropriately investigated.
• Registrars should consult with senior clinicians prior to administering steroid injections where there are atypical signs for frozen shoulder.
• Relevant records should be available to clinicians.

In relation to complaints handling, we recommended:

• Complaint responses should respond to all key points raised by the complainant.

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 their late relative (A) received at Glasgow Royal Infirmary. A was admitted to hospital for an elective keyhole procedure (a surgical procedure that allows a surgeon to access the inside of the abdomen and pelvis through a small hole in the skin) to remove part of their bowel due to cancer. Shortly after, their condition began to deteriorate due to what was later found to be a bowel obstruction and they died. C said that clinicians failed to diagnose A's bowel obstruction within a reasonable time and that their communication with the family was not reasonable in light of A's deteriorating condition and their treatment decisions.

We took independent advice from a general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We found a number of failings in the diagnostic process that meant clinicians failed to diagnose and treat A's condition (including kidney function) in a reasonable way. These failings included: lack of CT scan; not recognising symptoms indicated a bowel obstruction; continuing treatment unreasonably based on early x-ray findings of constipation; lack of clear evidence in medical records that the importance of the nasogastric tube (a tube passed through your nose and down into your stomach) was discussed with A. We also found that communication between the relevant healthcare professionals and A's family was not reasonable given the potentially catastrophic consequences of A's refusal of a relatively straightforward and potentially lifesaving intervention. We upheld both of C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with a reasonable standard of medical care and treatment and for failing to ensure medical staff communicated with A's family in a reasonable way. 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:

• Review the clinical failings to ascertain: how and why the failings occurred; any training needs; and what actions will be taken (or since then have been taken) to prevent a future recurrence. Before doing so, the board should consider why a previous review failed to identify the failings.
• Ensure record-keeping by healthcare professionals is of a reasonable standard.
• Ensure timely and appropriate communication between clinicians and family members when there is a threat to life.

In relation to complaints handling, we recommended:

• Ensure board investigations identify and address incidents covered by the duty of candour with the relevant Scottish Government 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 actions of the board in respect of their late parent (A). After being examined by their GP due to stomach pains and an irregular heartbeat, A was admitted to hospital. A was initially admitted to the hospital's Initial Assessment Unit (IAU). C stated that, when A was examined in the IAU, the family informed the doctor about A's history of having an abdominal aortic aneurysm (AAA, a bulge or swelling in the aorta, which is the main blood vessel that runs from the heart down through the chest and stomach).

A was transferred to a ward for further investigation. During this time, A's stomach pain increased. Clinical staff initially considered this as the result of constipation. On speaking with C, a doctor stated they were not aware of A's history of AAA. After further investigation, the doctor told the family that complications with the AAA could be ruled out. Shortly afterwards, A's condition deteriorated and a CT scan showed a leaking AAA. It was decided that it was not appropriate to operate and A died later that day.

C complained about the treatment A received and, in particular, that clinical staff unreasonably delayed diagnosing a leaking or ruptured AAA despite being informed of A's history. In addition to this, C complained that the doctor they spoke with after A's death did not report the matter to the Procurator Fiscal despite giving the impression they had done so. Finally, C complained about the fact that the same doctor did not write to them following A's death, after telling them this would happen.

In respect of the first complaint, we took independent advice from a specialist in acute medicine. We found that, given A's presentation at the time, the actions and decision-making of clinical staff was reasonable. The records showed that the possibility of a ruptured AAA was considered after A was transferred to the ward. However, given the outcomes of examinations and investigations carried out, this diagnosis was considered unlikely. Instead, an alternative diagnosis of pneumonia was initially pursued, with a secondary complaint of abdominal pain attributed to known constipation. We found that these conclusions were reasonable and justified by the recorded evidence. We also found that there was not sufficient evidence to reach a conclusive view on whether the IAU doctor was aware of A's history of AAA. We, therefore, did not uphold this complaint.

In respect of the second complaint, we noted that The Crown Office & Procurator Fiscal Service has produced guidance called Reporting Deaths to the Procurator Fiscal: Information and Guidance for Medical Practitioners. One situation where deaths should be reported is where the nearest relatives of the deceased raise concerns that the medical treatment given to the deceased may have contributed to their death. Given the evidence available about the conversation between C and the doctor following A's death, we could not reach a conclusive view on whether the Procurator Fiscal should have been informed at this point. However, another situation where deaths should be reported to the Procurator Fiscal is where a death certificate has already been issued and a complaint is later received which suggests an act or omission by medical staff caused or contributed to the death. This did not happen in this case and, therefore, we upheld this complaint.

The final complaint related to the doctor who spoke with C following A's death and their failing to contact C about the outcome of a meeting that was to take place. We noted that the doctor had acknowledged there was an unacceptable delay in writing to C. However, we did not consider the board's stage 2 response to contain an explanation for such a delay or indicate that any reflection had taken place about what went wrong. We reviewed the statement provided by the doctor as part of the board's complaint investigation and considered this to provide far more context about what happened. If the board had provided a fuller response that reflected the doctor's statement, C may have had a better understanding of what happened and considered this aspect of the complaint closed. We upheld this complaint because there was a clear failing, which had already been acknowledged by the board. We also provided feedback to the board about the importance of providing open and transparent explanations when acknowledging failings in complaint responses.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to inform the Procurator Fiscal of A's death, following the complaint made by C. 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 line with the guidance issued by the Procurator Fiscal, deaths should be reported where, at any time, a death certificate has been issued and a complaint is later received by a doctor or by the health board, which suggests that an act or omission by medical staff caused or contributed to the death.

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). A had a fall at home and was admitted to hospital due to a fractured hip. C was concerned that A was discharged from hospital only a few days after they had surgery. We took independent advice from an orthopaedic surgeon (specialist in diagnosing and treating conditions involving the musculoskeletal system) and an occupational therapist. We found that a comprehensive occupational therapy assessment was carried out prior to A's discharge which fully considered A's home environment and that the decision to discharge A four days after surgery was reasonable and met the targets set out in the Scottish Standards of Care for Hip Fracture Patients. We also found that the discharge and medications were discussed with A.

We, therefore, did not uphold C's complaint about A's discharge from hospital.

C also complained about the way the board handled their complaint. We found that the board did not always proactively update C or provide a revised timescale when they could expect to receive the response to their complaint. Therefore, we upheld C's complaint in this regard.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not always proactively updating them or providing a revised timescale for when they could expect to receive a response 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:

• Where the 20 working day timescale for a response cannot be met, the complainant must be kept updated on the reason for the delay and given a revised timescale for completion.

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.