Health

Summary

C complained about the care and treatment the board provided to their parent (A) after they stepped on a rusty nail and it penetrated their foot. A was initially seen at their GP practice and was then referred to the board. We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system).

C said that the board failed to provide A with appropriate care and treatment at Woodend Hospital for their painful toe. We found that A should have been seen in hospital within 12 weeks of referral, but was not seen until nearly eight months later, and after a second referral was sent by A's GP. C also said that the surgeon planned to amputate A's fifth toe during surgery, when it should have been their fourth toe. While the decision to amputate the fourth toe was reasonable, we noted that there was nothing in the medical records recording the misunderstanding about which toe was to be amputated. We also found that the specific risks of the amputation surgery were not mentioned to A at the clinic appointment at which the proposed surgery was discussed. Therefore, we upheld this part of the complaint.

C also complained that the board failed to provide A with appropriate care and treatment after their toe surgery. They said that, when A's surgical wound was not healing, the consultant failed to carry out a pulse test (test of the peripheral vascular system) on A and failed to refer them to the vascular surgeons (specialists in the treatment of diseases affecting the vascular system including diseases of the arteries, veins and lymphatic vessels) sooner. We found that A's pulses should have been assessed at the clinic appointment at which amputation surgery was discussed, and this should then have led to investigations and vascular input prior to surgery, if an abnormality had been detected. We considered that the failure to carry out this assessment was unreasonable and we, therefore, upheld this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to deal with the referral from A's GP in a reasonable manner and see A within 12 weeks of that date; mention the specific risks of the surgery to A at the clinic appointment; record the misunderstanding about which toe was to be amputated in A's medical records; and assess A's pulses at the clinic appointment. 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' pulses should be assessed and recorded at clinic appointments, in cases where foot and ankle surgery is being considered.
• Patients should be informed of the specific risks of surgery at clinic appointments where surgery is discussed and this should be documented.
• Relevant details, including where appropriate, misunderstandings about surgery should be recorded in patients' medical records.
• The board should have appropriate systems in place to assess GP referrals in cases such as this and ensure that patients are seen within an appropriate 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 complained to us on behalf of their late parent (A). A was admitted to Forth Valley Royal Hospital after falling at home. A few days into their admission, A was diagnosed with pneumonia (a chest infection) and then later developed sepsis (a severe complication of infection). A's condition deteriorated and they died.

C complained about A's medical treatment; in particular, that there was a delay in recognising and treating A's sepsis. We took independent advice from a geriatric (medicine of the elderly) adviser. We found that A's medical care and treatment was reasonable. We did not uphold this complaint.

C also complained about A's nursing care. C said that A was not given enough help with personal care and that their conversations with nursing staff had not been recorded adequately. We took independent advice from an acute nursing adviser. We found that the standard and frequency of the communication recorded appeared reasonable. However, we found that there was a lack of evidence of regular and appropriate care rounding to meet A's personal care needs. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A's nursing care. 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 timely and appropriate nursing care.

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 us about the care and treatment provided to their late parent (A). A was admitted to Forth Valley Royal Hospital. A few weeks later, A was transferred to Stirling Community Hospital. A developed pneumonia (a chest infection) and was transferred back to Forth Valley Royal Hospital a few days later. A's condition deteriorated and they died.

C complained about A's medical treatment; in particular, that there was a delay in responding to A's chest infection. We took independent advice from a geriatric (medicine of the elderly) adviser. We found that when A's condition worsened at Stirling Community Hospital, A should have been urgently reviewed by medical staff in case A had sepsis (a severe complication of infection). We found that when A's condition worsened significantly at Forth Valley Royal Hospital, A was not given prompt and appropriate antibiotic treatment for possible sepsis. We found that A was not reviewed by medical staff within reasonable timeframes. We also found that anticipatory care planning had not taken place with A and their family, given it was likely A had been nearing the end of their life before they had developed pneumonia. We upheld this complaint.

C also complained about A's nursing care at Forth Valley Royal Hospital; in particular, that A was not given appropriate falls care, and, that A was not given enough help with personal care. We took independent advice from an acute nursing adviser. We found that nursing staff should have formed and recorded a specific plan to address A's risk of falls at night/overnight, as that was when A was at highest risk of falling. We also found that there was a lack of evidence of regular and appropriate care rounding to meet A's personal care needs. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A's medical and nursing care. 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:

• If a patient is particularly at risk of falls at night or overnight, a clear plan should be put in place to address this and it should be recorded appropriately.
• If a patient or their relatives/carers raise concerns about the patient's medical care, this should be escalated to the senior medical staff overseeing their care; and concerns about nursing care should be escalated to senior nursing staff.
• If a patient's condition has worsened and it could be due to sepsis, this should be recognised and treated appropriately, in line with the board's antibiotic protocol.
• Patients should be given timely and appropriate nursing care.
• Senior medical staff should be updated if their patient's condition materially changes.
• There should be safe and effective medical handover between medical teams so patients are re-assessed within appropriate timeframes.
• Where appropriate, there should be sensitive and timely discussions with patients and their relatives/carers about anticipatory care planning.

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 had experienced pain and numbness in their hands over a period of years and was referred to the board for treatment. C underwent some tests and was offered repeat carpal tunnel surgery. C complained that the board failed to provide reasonable care and treatment. Unhappy with the board's response to their complaint, C brought the complaint to our office.

We took independent advice about all the complaints raised with us.

C complained that the board failed to carry out reasonable tests and investigations prior to their surgery. While we considered that the rationale provided by the surgeon in relation to what tests were carried out was reasonable, we questioned whether this was reasonably explained to C. We considered that the contemporaneous records did not evidence a thorough assessment of C's condition prior to the surgery being carried out. Therefore, we upheld this aspect of C's complaint.

C complained that the board unreasonably carried out surgery to their hands. We considered that the decision to undertake the revision surgery was reasonable, albeit that further investigations could have been carried out prior to this. C had previously had carpal tunnel surgery. We noted carpal tunnel can recur and it was reasonable for a second operation to be considered. On that basis the offer of surgery was reasonable. We did not uphold this aspect of C's complaint.

C complained that the board failed to offer a reasonable treatment plan after their surgery. We considered that after it was found the surgery had been unsuccessful, the actions recommended by the surgical team were reasonable. They offered to refer C back to the pain clinic and, after this was declined, discharged C back to the care of their GP. We concluded the board's treatment plan and actions regarding pain management were reasonable. We did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably evidence a thorough assessment of C prior to undertaking surgery and for the administrative error regarding the nerve conduction test results. 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:

• Clinicians should ensure the assessment of a patient is accurately recorded including the rationale behind decision-making.

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 submitted a complaint on behalf of their late sibling (A) about the treatment A had received by the board over a five-month period. A had a mass in their abdomen which led to a referral to urology (specialists in the male and female urinary tract, and the male reproductive organs) and later gynaecology (specialists in the female reproductive systems). A was initially diagnosed with pedunculated fibroids (noncancerous growths in the uterus) but it was later found by a different health board that A had cancer. C considered that the treatment provided by the board was unreasonable and led to a delay in A receiving the correct diagnosis.

C complained that the board failed to reasonably diagnose A after they were referred by their GP. We took independent advice from a specialist. We considered that the initial investigations carried out were reasonable, however, after the MRI results were received, the board failed to reasonably respond to this. The MRI result did not match with A's clinical picture and we considered that there was an unreasonable failure that this was not recognised and steps taken to investigate it further in a reasonable timescale. We considered that there was a failure in clinical judgement relating to this. Therefore, we upheld this aspect of C's complaint.

C also complained that the board failed to provide reasonable treatment when A attended A&E. We took independent advice about this complaint. We found that the investigations carried out were reasonable; we noted that further actions could have been taken, but the lack thereof was not in itself unreasonable, given the remit of A&E to only deal with emergency presentations. On balance, we did not uphold this aspect of C's complaint.

Recommendations

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

• Where radiological findings do not fit with the clinical picture a further review should be undertaken.

In relation to complaints handling, we recommended:

• Complaint responses should be accurate and respond to each main point raised.

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 their partner (A) was inappropriately prescribed a strong opiate painkiller by their GP, that they developed severe mental and physical health problems as a result of being kept on this medication for too long, that A was not appropriately reviewed while on this medication, and that their requests for help were not acted upon.

We took independent advice from a GP, who considered whether the prescribing to A was reasonable in the circumstances. They found no evidence to support that the long-term prescribing of the medication contributed to the deterioration in A's mental and physical health. They noted there was evidence of regular review and discussion of A's pain and pain relief. We accepted this advice and did not uphold this complaint.

However, we noted some complaint handling issues. The practice did not initially request consent from A to enable them to take C's complaint forward. Additionally, there were subsequent delays in preparing their response and they did not keep C updated or agree an extension to the target timeframe. We advised the practice to review their handling of C's complaint and ensure mechanisms are in place to ensure compliance with the NHS Scotland Complaints Handling Procedure.

Summary

C complained about the care and treatment they received at Victoria Hospital for their broken wrist. C had surgery on their wrist but developed swelling and pain two months later. C's GP referred them back to the board but C felt that they could not wait for 12 or more weeks to see an orthopaedic doctor (a specialist in the treatment of diseases and injuries of the musculoskeletal system) on the NHS, so obtained private treatment.

We took independent advice on this complaint from a consultant in emergency medicine and a consultant orthopaedic surgeon.

C said that they were not given adequate pain relief when they first attended the hospital. We found that the timing and type of pain relief given to C appeared reasonable, but the board failed to record pain scores for C and this was unreasonable. As there was no record of C's level of pain, we were unable to conclude with certainty that C's pain was adequately controlled.

C complained that the board failed to contact them about surgery after they were sent home and advised to wait to be contacted. We found that the board failed to contact C in a timely way to advise them when their surgery would take place.

C also complained that there was a delay in the surgery taking place. We concluded that the ten day delay in C's surgery taking place was unreasonable. However, whilst acknowledging the significant pain and uncertainty experienced by patients in such cases, we found no evidence that the delay had been ultimately detrimental to C's clinical outcome.

C said that they felt they could not wait for 12 or more weeks to see an orthopaedic doctor on the NHS, so had to obtain private treatment. We did not conclude that C had no choice but to obtain private treatment, as it could not be assumed that C would have been back to driving and other manual tasks more quickly, if they had been seen sooner. However, we noted that C's GP referral should have resulted in C being reviewed within four weeks at the fracture clinic or its equivalent, with contact being made with the patient by approximately 12 days of receipt of the referral to advise them of the review.

We also found that in their stage 2 complaint response, the board failed to address the issues C raised in their complaint regarding communication about the surgery, delay in the surgery taking place and C considering they had to obtain private healthcare.

We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to record a pain score for them; contact them in a timely way to advise them when their surgery would take place; carry out C's surgery within a reasonable time; evidence that C's GP referral was assessed appropriately; and address all the issues C raised in 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:

• The board should carry out surgery in cases such as this within a reasonable time.
• The board should have a reliable mechanism in place whereby out-patient trauma is queued appropriately and patients informed of their status timeously, particularly as some of them might be fasting.
• The board should have appropriate systems in place to assess GP referrals in cases such as this and ensure the action taken is appropriately documented in the medical records.
• The board should record pain scores for patients when they present at the emergency department.

In relation to complaints handling, we recommended:

• The board's stage 2 responses to complainants should address all the issues raised and demonstrate that each element has been fully and fairly investigated, in accordance with the NHS Model Complaints Handling Procedure.

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 provided to their late spouse (A) by the board in relation to the diagnosis, treatment, and management of A's cancer, especially regarding a delay in A receiving a Positron Emission Tomography scan (PET, a scan that produces detailed 3D images of the inside of the body). We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines). We found that A's cancer pathway took 17 months, which was significantly longer than it should have taken. We found that the most significant issue for the delay in the process was the error which resulted in the PET scan not being booked, as requested by the multi-disciplinary team (MDT). Additionally, the PET scan should have been requested on a suspected cancer pathway and we were critical that this was not the case.

We found that the delay in A's diagnosis was unreasonable and on balance, due to the increase in size of A's tumour during the delay, it is likely this negatively impacted on their outcome. We considered that the care and treatment A received from the board was unreasonable and upheld this aspect of C's complaint.

C also complained about the out-of-hours service (OOHS). A developed a postoperative wound infection, and was admitted to hospital. C complained that the OOHS, who saw A prior to admission, requested a non-life-threatening response from the Scottish Ambulance Service (SAS), rather than a life-threatening ambulance. We took independent advice from a GP. We found that the OOHS GP requested the ambulance in line with the SAS guidance, and any delays in the ambulance attending were outwith the GP's control. Therefore, we did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with reasonable 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:

• MDT requests for investigations, booking of investigations, results being shared, and follow-up MDT discussions should be actioned as soon as possible in cancer pathways.
• Patients and their family should be appropriately involved in discussions regarding their condition and management and these discussions should be recorded in the patient's notes.
• Requests from MDTs should be emailed directly to the clinicians to be actioned, rather than being sent to the gastrointestinal secretaries to be passed to the consultants.
• Where cancer is being considered as a strong possibility within the differential diagnosis, a PET scan should be requested on a suspected cancer pathway.

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 told us that their spouse (A) had been under the care of a cardiologist (a specialist that deals with diseases and abnormalities of the heart) who saw them at least once a year for review appointments following surgery, until their death twenty years later. A scan taken six years before their death showed a chronic dissection of the descending thoracic aorta (a serious condition in which there is a tear in the wall of the major artery carrying blood out of the heart). Clinicians decided to manage A's condition conservatively, but C told us neither they nor A were aware of this or the findings of the scan. C was also concerned that clinicians failed to carry out regular scans to monitor A's condition until shortly before their death and that communication between different specialists had been poor.

We took independent advice from a consultant cardiologist. We found a number of failings that had an impact on the board's ability to monitor A's condition which in turn meant that their treatment plan was not fully informed. These failings included: lack of records relating to A's operation and x-rays which made interpretation of later scans more difficult; lack of follow-up on whether additional imaging and/or cardiac opinion was needed following the scan showing the dissection; results of a CT colonoscopy (a procedure that uses a CT scanner to produce detailed images of the colon and rectum) were not shared or acted upon. We also found that communication between the relevant healthcare professionals was not as effective as it should have been given A's complex clinical condition. We upheld both 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 at www.spso.org.uk/information-leaflets.

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

• Ensure communication between clinicians from different specialisms is effective.
• Ensure record-keeping by healthcare professionals is of a reasonable standard.
• Ensure that significant test results are followed up appropriately.
• Feedback the findings of our investigation in relation to further tests and referrals to other specialists to relevant staff for them to reflect on.

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, a support and advocacy worker, complained about the standard of medical and nursing care and treatment provided to their client (A) during A's hospital admissions at Victoria Hospital and Cameron Hospital over 11 months. The concerns raised cover numerous aspects of the care and treatment provided by clinicians at A&E and the intensive care unit at Victoria Hospital, and clinical staff at Cameron Hospital. These include unreasonable failures in relation to the response to A's deterioration, medication including dosage, communication, bedsores, rehabilitation, and discharge. C also said that the board failed to handle A's complaint in a reasonable way. C told us that as a result of the failings, A developed complications which have had a profound impact on them and their spouse's life.

We took independent advice from four advisers: consultants in emergency medicine, psychiatry and anaesthesia, and a nurse specialist in tissue viability. We found that A had not been regularly reassessed as they should have been in A&E for a number of hours during which time their condition deteriorated and their transfer to the intensive care unit was delayed, and that staff in A&E failed to communicate with A's spouse in a reasonable way. We found that clinicians failed to take reasonable action to prevent hospital-acquired pressure damage to A and then failed to investigate and treat A's pressure ulcers, which led to severe and extensive pressure damage to a degree rarely seen in today's healthcare setting. We noted that this was avoidable and that the board's failure to identify these failings in their subsequent review was very concerning. We also found that the board's response to the complaint about A's condition and its cause did not reflect the evidence from the clinical records and advice obtained from specialists. We upheld five of C's complaints.

We did not find failings in relation to medications, communication from clinical staff in intensive care, transfer, handling of A by nursing staff at Cameron Hospital, rehabilitation care and treatment and discharge. We did not uphold eight 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 onapology 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.
• Ensure patients are regularly assessed so that any deterioration is noted and respond to appropriately and within a reasonable time.
• 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 their previous review failed to identify the failings and ensure that the methodology of this review is robust and that whoever undertakes it is appropriately qualified, objective and impartial.

In relation to complaints handling, we recommended:

• Ensure all complaint responses are accurate and reflect the available evidence and information.

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.