Health

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.

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.