Health

Summary

C complained on behalf of their parent (A) about the care and treatment they received during an admission to Ninewells Hospital. A was given a working diagnosis of a urinary tract infection (UTI) with delirium but was later diagnosed with encephalitis (inflammation of the brain). C said that because A regularly suffered UTIs, assumptions were made that A was experiencing the same again. C said that, as a result, appropriate investigations were not carried out and there was an unreasonable delay in diagnosis which affected A's outcome.

The board said that a UTI had been given as a reasonable working diagnosis and that blood and urine tests confirmed this. They considered that A had been treated reasonably in the circumstances.

We took independent medical advice. We found that at the time of their admission, A had non-specific symptoms which were reasonable to diagnose as a UTI. When A deteriorated and their symptoms changed, A was cared for reasonably with an appropriate degree of urgency, and a prompt diagnosis of encephalitis was made. While A suffered a poor outcome, we could not conclude that this was as a result of an unreasonable delay in diagnosis. We did not uphold C's complaint.

Summary

C suffered from a gastrointestinal (stomach) disorder and was receiving treatment from the board. C complained that the treatment in response to their condition was unreasonable.

We took independent advice from a consultant hepatologist and gastroenterologist (specialist in disorders of the gastrointestinal tract, liver, pancreas and gall bladder). We found the clinicians involved in C’s care considered both the physical and psychological elements relating to C’s condition, undertook reasonable investigations into their condition and provided reasonable treatment in terms of C’s symptoms. We noted that it was reasonable in conditions such as C's, where there was no cure, to focus on the management and improvement of symptoms and prevent harm. As such, we did not uphold this complaint.

C complained that the board failed to reasonably respond to their complaint. We found that the board failed to reply to all the points raised by C. C raised a number of concerns regarding the treatment they had received. In response, the board advised that the review undertaken indicated that clinical management was appropriate; however, no details were provided to explain how they had reached that view. While we considered it was reasonable that the board focused on a way forward, to ensure appropriate treatment was carried out in the future and this was a resolution-based approach, this did not remove the requirement to respond to the points C had raised about previous treatment. There was also an unreasonable delay in responding to C’s complaint. As such, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide a reasonable response to their complaint. The apology should meet the standards set out in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Complaint responses should respond to all of the points of complaint raised by a complainant and be issued in a reasonable 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 has felt that they have obsessive compulsive disorder (OCD) for some years. C has seen various clinicians at the board about this but does not feel that they received appropriate care or treatment. C complained to the board about their care and treatment over the previous years. C said that a psychologist did not provide reasonable care or treatment, that a community mental health nurse did not provide reasonable care and that a psychiatrist unreasonably diagnosed C with anxiety.

In their responses, the board told C that the psychologist had reviewed their care and treatment. The board outlined the care and treatment C had been offered and had taken up and concluded that C’s care and treatment had been handled reasonably. C was dissatisfied with the board’s response and raised their complaints with our office.

We found that the overall standard of treatment provided to C between the period in question by all of the board staff complained of was of reasonable quality and in line with relevant guidance. We did not uphold the complaints.

Summary

C complained on behalf of their partner (A) about surgery they had on their hip. A, who had previously had their hip replaced, was admitted to hospital with an infection which was found to have originated in their hip and required surgery (the first surgery). The following year, A developed pain in their hip again. Scans confirmed that this would again require surgery, which was carried out later that year (the second surgery). A was discharged shortly after, but required to be readmitted twice due to pain. On the second readmission a fracture was identified above their knee, requiring additional surgery. C complained about the first surgery, the second surgery, the aftercare A received and how the board responded to their complaint.

We took independent advice from a consultant orthopaedic surgeon (a surgeon who specialises in the musculoskeletal system). We found that the first surgery was carried out appropriately. C had been concerned that the surgeon had used an incorrectly sized piece of orthopaedic equipment (a stem), however, we noted that the surgeon either used an identical, or slightly smaller stem as they decided not to remove the original cement. We found that this was reasonable.

We found that the second surgery was also carried out appropriately. The surgeon cut a small ‘window’ in the bone to facilitate removal of the cement which was established practice. We considered that this was probably the source of the fracture which A was later found to have, however, there was no indication of a fracture at the time of the surgery.

We were satisfied that the care and treatment A received after their second surgery was reasonable.

As the evidence indicated that the clinical care provided was reasonable, we did not uphold these complaints.

In relation to complaint handling, we found that there was miscommunication regarding delays and a failure to clarify all the issues of complaint. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for miscommunication regarding delays and a failure to clarify the confusion surrounding point two in the complaint response. 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:

• For the findings of this investigation to be shared with staff.

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

The complainants (B & C) raised concerns about the practice following the suicide of their child (A). A and B had attended the practice two weeks prior to A’s death and B & C told us that they held concerns regarding the manner of the GP they saw, which A and B had found to be dismissive and unsupportive. While they did not consider that the doctor could have predicted the extent of A’s distress, they considered that the doctor’s demeanour may have contributed towards A feeling unsupported.

B & C also held concerns regarding the way in which the practice had cared for them following A’s death, as they had concerns about a prescription for Diazepam (a drug which belongs to a group of medicines called benzodiazepines and usually used to treat anxiety) they both received, the lack of other support offered, and the way in which the practice carried out a Significant Adverse Event Review (SAER) into what had occurred.

On investigation, we found that the doctor in question had already accepted that their body language had been inappropriate and apologised for this, when responding to B & C’s original complaint. We took independent advice from a GP on the care and treatment offered and we considered that the support provided by the doctor at the appointment was otherwise reasonable. Therefore, we did not uphold that element of the complaint.

We considered that the handling of the prescription of Diazepam and the bereavement support otherwise offered to B & C had been inappropriate. We also found that the SAER had been unreasonably delayed. Therefore, we upheld these complaints.

Recommendations

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

• Patients should be appropriately consulted before being prescribed benzodiazepines; patients should not be prescribed benzodiazepines for longer than is appropriate; the practice should consider whether prescribing benzodiazepines is appropriate for grieving families, given this may impair their grief reaction; and grieving families should be contacted with offers of support.
• Significant Event Analysis Reviews should be completed in a timely manner and identify any failings in treatment, as appropriate.

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 member of the Scottish Parliament, complained on behalf of one of their constituents (A) about the care and treatment they received from the board.

Initial investigations carried out diagnosed A with atrial fibrillation (AF, a problem of the heart characterised by irregular and often faster heartbeat). While waiting for a cardiology (the branch of medicine that deals with diseases and abnormalities of the heart) appointment, A suffered a heart attack and was admitted to Hairmyres Hospital.

C raised concerns that the hospital’s cardiology department knew A had a problem with their heart two weeks before they suffered the heart attack and that aspects of A’s care and treatment during their admission were unreasonable. In particular, they complained that A was placed in a bed next to a disruptive patient who was suicidal while in the Acute Assessment Unit (AAU), that there was a delay in carrying out a coronary angiogram procedure (a type of x-ray used to examine blood vessels), and that communication by hospital staff was poor. C also complained that A’s follow-up rehabilitation treatment after discharge was unreasonable.

We took independent advice from a cardiology adviser. We found that while there were issues identified initially with A’s heart, there were no concerning features associated with their AF that would raise suspicion that A might have a heart attack.

While we acknowledged that being in a bed next to a disruptive patient in AAU, must have been very distressing for A at a particularly difficult and anxious time, we found that this reflected the status of AAU as a communal assessment ward and was consistent with standard practice.

Regarding C’s concerns about the delay in the carrying out of the coronary angiogram, we found that it was reasonable for staff to delay this procedure in the context of staff being required for other urgent and emergency procedures.

We acknowledged C’s concerns about staff communication and how this made A feel, in particular, surrounding the delayed angiogram procedure. While A had expected some face-to-face contact with their consultant, and although this did not occur, we did not find sufficient evidence to show that there was a failure in communication. However, we provided feedback to the board about this.

In terms of the care provided following A’s discharge, we found this was of a reasonable standard.

We found that the overall care and treatment provided to A was reasonable. As such, we did not uphold this complaint.

C also complained that the board did not respond reasonably to A’s complaint. We upheld this complaint on the basis that the board did not address all aspects of A’s complaint in their response.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to address all aspects of A's complaint in their response letter. 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:

• Complaint responses should address the issues raised by the complainant, in line with the 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 was diagnosed with pleomorphic lobular carcinoma in situ (PLCIS, an uncommon condition in which abnormal cells form in the milk glands (lobules) in the breast). Following excision of the carcinoma, a programme of 15 radiotherapy treatments was undertaken by the board to reduce the risk of recurrence. Subsequently, C experienced breathlessness and an increase in phlegm. Clinicians initially felt this may be due to radiation pneumonitis (inflammation of the lung caused by radiation therapy) before a likely diagnosis of cryptogenic organising pneumonia (COP, a rare lung condition) was reached. A consultant oncologist (cancer specialist) told C’s GP that COP was a rare toxicity of breast radiotherapy. C wrote to and met with the consultant oncologist to detail their concern that the fourth fraction of their radiotherapy had not been undertaken accurately. The consultant oncologist investigated the matter but did not consider there were any discrepancies or irregularities regarding C’s positioning for radiotherapy. C complained to the board about these matters. The board’s investigations did not indicate that their actions had been unreasonable and they advised C of this. C remained dissatisfied and brought their complaint to us.

We took independent advice from an appropriately qualified adviser. We found that the board had provided reasonable treatment to C and had taken steps to rectify the poor communication to C before we became involved with the complaint. We found evidence that it was reasonable to conclude that C was advised of alternative treatments to radiotherapy. We concluded that the board responded reasonably to C’s complaint. We did not uphold C’s complaints.

Summary

C complained about the care and treatment they received from the board when they were seen during pregnancy for symptoms of pain and bleeding. C had a colposcopic assessment (a simple procedure used to look at the cervix, the lower part of the womb at the top of the vagina), during which it was considered that there was no obvious cancer, but it was arranged for C to have a smear test (a test to check the health of the cervix) three months postnatally. C did not undergo the smear test and was later found to have cervical cancer. C complained that the board did not appropriately investigate their symptoms; that the postnatal follow-up was not appropriate or timely; and that the need for postnatal follow-up was not reasonably explained to them. C was concerned that earlier diagnosis and treatment would have resulted in a better outcome for them.

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 the symptoms of pain and bleeding were appropriately investigated during C’s pregnancy; however, the board should have arranged for C to have a colposcopy three months postnatally, as opposed to being invited for a smear test. We also considered that the requirement for postnatal follow-up was not reasonably explained to C. Though it was not possible to know if the cancer was present when C was three months postnatal, we accepted the advice we received that it was likely, and that had it been diagnosed and treated at that time, C probably would have had a better outcome. We upheld this aspect of C’s complaint.

C also complained about the board’s handling of their complaint. We found that the board had not addressed all of the issues C raised in their complaint, and that the complaint response was unclear as to the need for a postnatal colposcopy. We upheld this aspect of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide them with reasonable care and treatment, and failing to respond to their complaint reasonably. 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:

• Postnatal colposcopy should be arranged in line with NHS Cervical Screening Programme: Colposcopy and Programme Management guidance.
• Requirements for follow-up care should be discussed with the patient and these discussions should be recorded.

In relation to complaints handling, we recommended:

• Complaint responses should address all relevant issues and should clearly explain the relevant clinical issues.

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 health board delayed in diagnosing and treating their cancer. C was referred by their GP to a number of specialists to investigate symptoms they were experiencing. C complained that the board failed to act in response to investigations, particularly MRI scans instructed by the pain management service, which showed a lesion (abnormal tissue) on their back. C was referred to hospital by their GP around three months following the MRI scans with increasing symptoms, and the decision was taken for C to undergo surgery to remove the lesion. C complained that as a result of the failure to act urgently on the results of the MRI scans, they had to suffer intense pain and the diagnosis and treatment of their cancer was unreasonably delayed.

In responding to the complaint, the board said that two MRI scans performed by the pain management service showed a lesion, but as there had been no change between the scans a follow-up in six months was indicated, with a referral to neurosurgery (specialists in surgery on the nervous system, especially the brain and spinal cord). When C attended hospital around three months later, a subsequent MRI indicated that the lesion had progressed and it was identified as the cause of C's symptoms.

We took independent advice from a medical adviser who considered that whilst the MRI scans carried out identified a cystic lesion, they did not reveal signs which required urgent follow-up and, at that time, a diagnosis attributed to a pre-existing condition was the plausible cause of C's symptoms. Investigations did not reveal any signs that would be considered urgent and, without progression in symptoms experienced by C, the radiology reports alone would not be acted upon. We found that investigations undertaken by the board were reasonable and we did not uphold the complaint.

Summary

C, an advocacy worker, complained on behalf of (B) about the care and treatment provided to B's family member (A) before their death. Around three months prior to A’s death, they attended their GP with back pain, nausea and feeling generally unwell. They subsequently attended Accident and Emergency (A&E) at Inverclyde Royal Hospital on two occasions, before being admitted to the Royal Alexandra Hospital via A&E there. A was diagnosed with a rare and aggressive type of cancer and died a short while later. C complained on behalf of the family that A was not investigated more thoroughly given their symptoms and medical history, and that the family was not included in discussions about A’s care.

We took independent advice from a consultant in emergency medicine. With regards to care and treatment, we found that appropriate investigations were carried out during A’s hospital attendances and reasonable management plans were put in place. While we considered that there could have been closer attention to pain measurement recording, and a referral to an out-patient clinic could have been made by A&E staff directly (rather than relying on A to re-attend their GP for this purpose), we accepted that improvements in these aspects of care would not have altered the outcome for A. On balance, we did not uphold this aspect of C's complaint.

Regarding communication with A’s family, we noted that A was a competent adult and it is not expected practice to involve family members in treatment decisions when the patient has capacity. The records indicated that medical staff did speak with A’s family on occasion and we were satisfied that they were not deliberately excluded from discussions. As we found no significant omissions in communication, we did not uphold this aspect of C's complaint.

C also complained about the board’s handling of the complaint. We found that the complaint was not responded to in a timely and robust manner. An initial meeting was held with A’s family but the board did not follow this up in writing. Additional questions and concerns developed during A’s family’s wait for a written response. Delays were not proactively explained and revised timescales were not communicated to C. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's family for the identified failures in the handling of 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:

• The board should ensure complaint investigations conform to the NHS Model Complaints Handling Procedure, particularly in terms of the requirement to respond in writing and in a timely manner. They should review their handling of this complaint with a view to identifying areas for learning and improvement.

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.