Health

Summary

C are asthmatic and suffer from chronic obstructive pulmonary disease (COPD). C was referred to the board by their GP due to a flare up of COPD. C was reviewed by a locum consultant respiratory (relating to or affecting the action of breathing or the organs associated) physician at Monklands Hospital. C was concerned that the decision was made to change their inhalers from Relvar and Incruse to a Trelegy inhaler. C said that this caused their condition to flare up and resulted in their breathing becoming laboured.

We took independent advice from a consultant in respiratory and general internal medicine. We found that a clinic letter from a few years earlier did not make it clear that a diagnosis of asthma (in addition to the confirmed diagnosis of COPD) was suspected nor list the medication with doses that C was receiving. We noted that the lack of clarity regarding C's suspected diagnosis and treatment resulted in C's GP and subsequent hospital consultants not being aware that C had a possible diagnosis of asthma and was on the higher steroid dose of Relvar. Based on the information known to the consultant at the time, it was reasonable to consider combining the Relvar and Incruse inhalers in to a Trelegy inhaler. However, there was no evidence in the records that the change in medication was explained to C in a reasonable way. In particular, we noted that the possible risks and benefits of this change were not explained to C so that they could make an informed choice about whether to make the change.

In these circumstances, we considered it was unreasonable for the board to substitute the medication C was taking for their respiratory condition (Relvar and Incruse) with a Trelegy inhaler. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to make it clear that a diagnosis of asthma was suspected or list the medication with doses that C was receiving on the clinic letter and for failing to make C aware of the possible risks and benefits of changing their inhalers so that C could make an informed choice about whether to make the change. 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:

• Changes to inhalers should not be recommended without discussing the risks and benefits with the patient first.
• Clinic letters should clearly list confirmed and suspected diagnoses and treatment (including type of dose).

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 a family member (A) received in Monklands Hospital prior to their death. C raised particular concerns that nursing care was not delivered proactively and that the family had to continually ask for care to be provided, including catheter care, oral care, nutrition and pain management. A suffered a fall while in hospital and C also raised concerns about the adequacy of the medical assessment which was carried out following this.

We took independent advice from a nursing adviser. We found that the nursing care was reasonable overall, with appropriate care rounding evidenced in the records. This covered catheter care, pain management and general care. However, we identified an unreasonable two-hour delay in commencing appropriate medication for pain and agitation due to medical staff being unavailable to prescribe. We also identified that prescribed oral care was not administered as prescribed, and that person-centred care planning did not reflect A's needs with regards to oral hygiene and end of life needs. We considered that this contributed to A's noted discomfort in the final days of their life and, on balance, we upheld this complaint.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) regarding the medical assessment which followed A's fall. We noted that a thorough and well-documented assessment was carried out which concluded that A had sustained minor injuries only and that no scans or further investigations were required. We did not consider there was a clear connection between the fall and its follow-up and A's subsequent deterioration. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in commencing appropriate medication for A's pain and agitation; the failure to administer oral care as prescribed; and for the failure to update the person-centred care plan to reflect A's needs. 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:

• Person-centred care plans should be updated at every shift change to capture person-centred needs. The board should carry out a review of person-centred care planning in the relevant ward.
• The board should investigate why medical staff were unavailable to prescribe timely medication for pain and agitation. Measures should be put in place to prevent this happening again; and the board should demonstrate compliance with the Scottish Palliative Care Guidelines 2013.
• Treatment should be administered as prescribed, or a code entered in the medicine kardex to indicate why this has not been administered. Ward staff should be reminded, in a supportive manner, of their responsibilities and the policy for the administration of prescribed medication.

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 relative (A). A had surgery for a fractured hip and wrist at Hairmyres Hospital. At a clinic appointment a few weeks later, A was advised that there was an issue with a screw being close to the joint in their hip. A was not keen on further surgery and there was an agreement to review them again in six weeks. Subsequently, A's pain increased and their mobility decreased. An x-ray showed that the screw had failed; therefore, surgical correction was considered and further surgery was subsequently performed. A's clinical condition deteriorated and they died a number of weeks later. C complained to the board about A's care and treatment. The board responded to the complaint and carried out a review of A's care. The board identified some evidence of poor care.

C remained unhappy and complained to us about A's care and treatment and the board's handling of their complaint. We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and from a trauma and orthopaedic (a specialist in the treatment of diseases and injuries of the musculoskeletal system) consultant. We found that A was appropriately reviewed by medical staff and that there was no evidence of a delay in A's pain being identified following their first operation.

However, we identified that medication errors in relation to the prescription of vitamin D had occurred which were significant. Whilst we did not find evidence that the errors caused harm to A, the errors had not been appropriately documented in the medical records when they were identified; nor were they reported on the second occasion as they should have been. A and their family were also not informed about the medication errors at the time, contrary to General Medical Council (GMC) guidance. We were critical that the board's review of A's care did not take sufficient action to adequately address these errors.

We also found that, when A consented to further surgery (which was major and complex), there was no evidence to show that the option of a girdlestone procedure (removal of the metal work only which would have left A with a significant functional disability) had been discussed with A or their family. We considered that this was unreasonable and contrary to national guidance on consent.

We upheld the complaint on the basis that there was a missed opportunity for the board's review to adequately address failings in care and to fully learn from these events.

We also found that there were failings in the board's handling of C's complaint in that there was an unreasonable delay in investigating and C receiving their final response. We also considered that the board's response was inadequate in that it failed to identify and address the potentially serious medication errors that occurred. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to appropriately prescribe vitamin D; document and report the medication errors when they were identified; inform A and the family at the time; take sufficient action to address the errors when they were identified in the board's review; discuss the option of a girdlestone procedure; and handle C's complaint adequately. 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 fully advised of all relevant surgical options and the discussion should be clearly recorded, in accordance with relevant standards and guidance.
• Any reviews undertaken should sufficiently address any errors/failings identified.
• Medication should be prescribed safely. Medication errors should be appropriately documented in the medical records when they are identified and reported by the board's reporting system. Patients and their relatives should also be appropriately informed in line with GMC guidance.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the board's and 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, a support and advocacy worker, complained on behalf of their client (A) who was diagnosed with cervical cancer whilst they were undergoing fertility treatment. C complained that the board failed to investigate A's symptoms which they had been experiencing for a number of months, and that this led to a delay in diagnosis. C also complained that the board failed to carry out a reasonable investigation of the complaint as their response did not demonstrate that any real analysis was undertaken of the care and treatment provided to A.

The board confirmed their view that appropriate investigations were carried out. They explained that A had a type of cancer (endophytic, where there is no obvious cancer as it is within the body of the cervix) which is more difficult to diagnose.

We reviewed the clinical records and took independent advice from a consultant in gynaecologic oncology (a specialist in the diagnosis and treatment of cancers of the female reproductive system). We found that the referrals, tests and assessments were in line with best medical practice and within reasonable timeframes. As such, there was no missed opportunity to diagnose the cancer sooner. We also found evidence that the board's internal investigation of the complaint was thorough and reasonable. We did not uphold C's complaints, however, we did provide feedback on the board's handling of the complaint.

Summary

C was diagnosed with a malignant melanoma (a type of skin cancer) and referred to a consultant oral and maxillofacial (the specialty concerned with the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) surgeon for surgery. A wide local excision (WLE, a surgical procedure to remove a small area of diseased or problematic tissue with a margin of normal tissue) was carried out. C complained that they should have been offered a sentinel lymph node biopsy (SLNB, a procedure in which the sentinel lymph node is identified, removed, and examined to determine whether cancer cells are present) at the same time as the WLE, in accordance with clinical guidelines. C complained that without having had SLNB, their disease could not be accurately staged.

The board said their priority had been the excision and that on review by the surgical team SLNB was not recommended. C received a computer tomography (CT) scan and the report from this was discussed at the appointment attended with the consultant oral and maxillofacial surgeon. The consultant confirmed at the appointment that the pathology report staged C's melanoma at stage 2 (the melanoma is only in the skin and there is no sign that it has spread to lymph nodes or other parts of the body). C also received an ultrasound fine needle aspiration (FNA) of their right neck and biopsy. The board said accuracy of SLNB at this stage was limited and likely to carry more morbidity; therefore they suggested to follow up with six monthly CT scans and consideration of repeat ultrasound at alternate six monthly intervals. In their response to our enquiries, the board acknowledged that C ought to have had a SLNB at the time of their wide excision, providing their general medical fitness was appropriate for general anaesthesia.

We took independent clinical advice from an appropriately qualified adviser. The adviser confirmed that C met the criteria for SNLB to be offered in accordance with Scottish Intercollegiate Guidelines Network (SIGN) and National Institute for Health and Care Excellence (NICE) guidance. While the adviser noted C had an effective operation with no delays, there had been a missed opportunity for SNLB. The adviser considered the impact was hard to see, and that given C's good pathology report, which found no pathological lymph nodes by ultrasound and their internal organs free of melanoma, their prognosis was excellent. The adviser nevertheless considered that C ought to have been given the choice to undergo SNLB at the time of the WLE, and noted the effect on C was that they could not take part in melanoma trials nor could they have confidence in the possibility of being successfully treated. The adviser was critical of the board for not having ratified the guidelines. Taking all of the above into account, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to offer a sentinel lymph node biopsy at the time of excising their melanoma, with a recognition of the distress this matter has caused them. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information leaflets.
• In their apology letter, the board should explain to C why the guidelines have not been ratified and advise C of their future intentions in this regard.

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

• An action plan should be devised for ratification of the SIGN/NICE guidelines.
• The outcome of this complaint should be fed back to relevant staff in a supportive manner.

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.

Following publication on 24 March 2021, this complaint was subject to a review.  The overall outcome of the complaint remained unchanged however, amendments were made to both the summary and recommendations.  The summary as originally published can be found at the bottom of the page. 02/03/2022

Summary

C complained about the care and treatment they received from Inverclyde Royal Hospital. C underwent colorectal surgery during which it was identified that they had rectal cancer which had spread into the vascular system. Prior to the surgery, a lesion on C’s lung was noted but was not thought to be typical of cancer and a plan was made to keep it under review. C raised a number of concerns regarding the reasonableness of the management plan for their cancer and delays to their treatment. They considered that treatment decisions were made without their involvement and they were given misleading information about their treatment options.

We took advice from a general and colorectal surgeon who noted that the monitoring of C’s lung lesion was unstructured. We were advised that a CT PET scan was not carried out in a timely manner; there was no referral to a lung multi-disciplinary team (MDT) when scans subsequently showed an increase in lesions; and there was a delay in referring to oncology for discussion of treatment options. As such, C was not provided with a clear picture of their condition and management plan, and treatment was not instigated as soon as it might have been. While it was accepted that treatment options were limited and earlier treatment may not have altered C’s prognosis, earlier discussion with oncology could have cleared up some of the uncertainty and alleviated C’s associated distress. We accepted the advice and upheld this complaint. Whilst not raised in the complaint, the adviser also observed a failure during the colorectal surgery to check for a tattoo marker that had previously been placed to mark the tumour. While this did not result in a failure to fully remove the tumour, the adviser described it as a ‘near miss’.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C's next-of-kin for the lack of clarity in follow-up monitoring; the failure to refer C to the lung MDT and carry out a CT PET scan in a timely manner; the delay in referring to oncology; and the failure to check for the tattoo marker during surgery. 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 colorectal MDT should reflect on C's care and treatment and review its processes for referrals to oncology or other MDTs, to ensure appropriate input is received and acted upon.
• The colorectal MDT should review its processes in respect of ensuring there is a clear pathway for monitoring specific issues separate to standard post-surgical follow-up.
• The board should tell the Ombudsman what their process is for reporting and reviewing 'near miss' events, and why there was an apparent failure to identify this one.
• The colorectal team should discuss the failure to check for the tattoo marker during surgery, and how a similar future error can be avoided.

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.

Original summary published on 24/03/2021

Summary

C complained about the care and treatment they received from Inverclyde Royal Hospital. C underwent colorectal surgery during which it was identified that they had rectal cancer which had spread into the vascular system. Prior to the surgery, a lesion on C's lung was noted but was not thought to be typical of cancer and a plan was made to keep it under review. C raised a number of concerns regarding the reasonableness of the management plan for their cancer and delays to their treatment. They considered that treatment decisions were made without their involvement and they were given misleading information about their treatment options.

We took advice from a general and colorectal surgeon who noted that the monitoring of C's lung lesion was unstructured. A respiratory physician's recommendation was not followed up and C was not referred to a lung multidisciplinary team (MDT) when scans showed that the lung lesions had increased in size and number. The adviser also identified a delay in referring C to an oncologist for discussion of treatment options. As such, C was not provided with a clear picture of their condition and management plan, and treatment was not instigated as soon as it might have been. While it was accepted that treatment options were limited and earlier treatment may not have altered C's prognosis, earlier discussion with oncology could have cleared up some of the uncertainty and alleviated C's associated distress. We upheld this complaint. The adviser also observed a failure during the colorectal surgery to check for a tattoo marker that had previously been placed to mark the tumour. While this did not result in a failure to fully remove the tumour, the adviser described it as a 'near miss'.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C's next-of-kin for the lack of clarity in follow-up monitoring; the failure to refer C to the lung MDT and follow up the respiratory physician's recommendation; the delay in referring to oncology; and the failure to check for the tattoo marker during surgery. 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 review and identify why the respiratory physician's recommendation was not followed up.
• The board should tell the Ombudsman what their process is for reporting and reviewing 'near miss' events, and why there was an apparent failure to identify this one.
• The colorectal MDT should reflect on C's care and treatment and review its processes for referrals to oncology or other MDTs, to ensure appropriate input is received and acted upon.
• The colorectal MDT should review its processes in respect of ensuring there is a clear pathway for monitoring specific issues separate to standard post-surgical follow-up.
• The colorectal team should discuss the failure to check for the tattoo marker during surgery, and how a similar future error can be avoided.

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 treatment of their breast cancer was unreasonable. Following a routine breast screening, C was diagnosed with breast cancer. They underwent surgery and were told that the tumour was successfully removed and no further surgery would be required.

C was referred to the oncologist (a doctor who specialises in the diagnosis and treatment of cancer) for ongoing treatments including chemotherapy. Before commencing the treatments, it was identified that the initial surgery had not cleared the cancer. Further surgery was organised but that procedure was not successful. Chemotherapy could not be delayed further so C had to undergo a mastectomy (an operation to remove a breast).

Through its own investigation, the board acknowledged that there had been a failure to review the correct and relevant postoperative pathology information from C's surgery. Appropriate action was taken by the board as soon as the error was identified. We took independent advice from a consultant breast surgeon who agreed that overall the failing in C's case was very significant but that it did not result in significant harm as it was discovered and appropriate steps were taken to rectify it before any further treatments were commenced. We upheld this aspect of C's complaint but did not make any recommendations.

C also complained that the board failed to respond appropriately to their complaint. We found that the board took C's complaint seriously, they acknowledged that an error occurred and they committed to reviewing the process to ensure that the same kind of error would not happen again. The board also gave an appropriate apology. Therefore, we did not uphold this aspect of C's complaint.

Summary

C was taken into Queen Elizabeth University Hospital for a kidney removal after the discovery of a cancerous cyst. A few days after the operation they were detained under the Mental Health Act and transferred to Stobhill Hospital. C believed they were not physically fit for discharge at that stage, and that there was insufficient evidence of risk to justify detaining them. In addition, they considered that their medication was mishandled throughout their time in both hospitals and that staff failed to treat them with respect and dignity. C is also blind and felt that the board had failed to reasonably take account of this in the way they interacted with and cared for them.

We took independent advice from a nephrologist (a doctor who specialises in kidney care and treating diseases of the kidney), a psychiatrist and a nurse. We found that C's care and treatment was generally reasonable, with the exception of the handover between the two hospitals, which was insufficient and led to problems with the dosage of C's medication. On this basis, we upheld C's complaint that the board failed to provide reasonable clinical treatment, but did not uphold their other complaints.

Recommendations

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

• Reasonable handover notes should be provided when patients are transferred between hospitals, to ensure continuity of 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 attended their GP with shoulder pain and was referred to orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system) who, during the initial consultation, reviewed x-rays and ultrasound imaging and concluded no broken bones were shown. A was diagnosed with muscle patterning (when the pattern of muscle contractions is altered) and referred to the physiotherapy department for treatment.

C had a number of follow-up appointments and was discharged around four months later as it was considered that there was no further treatments they could be offered to alleviate the symptoms. C was then referred to the neurology department (the branch of medicine concerned with the diagnosis and treatment of disorders of the nervous system). Around the same time, after seeing a private doctor, C had an MRI scan and the results showed that C had broken ribs. C considered that medical professionals focused on their disability and other medical conditions, unreasonably delayed in diagnosing the broken bones and that it was only because they instructed a private consultant, that the injuries were diagnosed.

We took independent advice from an appropriately qualified medical professional. We found that the board performed appropriate investigations following C's referral by their GP. There was an appropriate multidisciplinary approach following the initial consultation involving physiotherapy, rheumatology (the branch of medicine that deals with rheumatism, arthritis, and other disorders of the joints, muscles, and ligaments), orthopaedics and neurology. The fractures identified occurred after the initial consultation and investigations carried out following the GPs referral. We considered that there was no unreasonable delay in diagnosing C's broken bones and therefore we did not uphold the complaint.

Summary

Ms C complained about the care and treatment she received at Queen Elizabeth University Hospital. Ms C underwent splenic artery embolization (a procedure that involves inserting a fine tube into the blood vessel that supplies blood to the spleen and deploying a device to treat an aneurysm). A complication occurred and following the procedure it was identified that a fine piece of filament was retained in Ms C's leg. A further procedure was performed the following day and the filament was removed. Ms C experienced significant discomfort during and after the procedure. Ms C remained dissatisfied following receipt of the board's response to her complaint and brought her complaint to us.

We received independent advice from a radiology adviser (a specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found that the first procedure was not performed reasonably as there was a failure to identify the retained filament before the procedure ended. We found that the second procedure was performed reasonably and we considered that the board had taken reasonable action to learn from the complication that occurred. Finally, we considered that the consent process was inadequate as it was not clear that Ms C was informed about the possibility of pain as a result of the procedure. We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings in care and treatment identified. 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 informed about discomfort and common relatively minor side effects following a procedure as well as more serious complications using simple terms.

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.