Health

Summary

C had taken steps to obtain a Welfare Guardianship Order in respect of their adult child (A). Part of this process involved C's solicitor requesting the production of a suitability report from the local council. Due to a variety of reasons, the production of a suitability report took a significant length of time. As part of the application process, C's solicitor sought an Adults with Incapacity report from A's new GP. Following this request, A's GP submitted an Adult Support and Protection (ASP) concern referral in respect of A. This referral was received by the board's Social Work Adult Services.

In response to this referral, the social worker who was allocated to A carried out a number of inquiries. This included contacting the mental health officer (MHO) at the council, who was tasked with producing the suitability report. C complained about the social worker's involvement in the guardianship application process. In C's view, the social worker inserted themselves into the application process in a manner that was beyond their remit and sought to delay or hinder the application. C also complained that the board and the social worker did not act in line with the relevant procedures in respect of the ASP process after receiving the concern referral.

We took independent advice from a social worker. In respect of the guardianship application process, the social worker did not act beyond their remit. Under the circumstances, it was appropriate for the social worker to make contact with the MHO after receiving the ASP concern referral. It was also appropriate for the social worker to provide their professional opinion in respect of the guardianship application. As such, we did not uphold this aspect of the complaint.

In respect of the ASP process, the board carried out their duties in line with their obligations and their inquiries were appropriate. However, the board failed to provide a reasonable level of clarity about whether their actions were taken under ASP legislation and guidance. We did not consider there to be evidence to indicate that the social worker acted in bad faith. However, in our view, the evidence showed a lack of clarity around why specific actions were being carried out and a lack of accuracy in the language used by the social worker in their correspondence. Therefore, although we were satisfied that the board's actions were in line with their obligations, we did not consider them to have been carried out reasonably. As a result, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to act reasonably after receiving an Adult Support and Protection concern referral in respect of A. 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:

• Adult services staff should ensure that actions taken after receiving an Adult Support and Protection referral are clearly and accurately communicated to relevant parties.

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 child (A) that the board had failed to provide A with reasonable care and treatment for a Phyllodes tumour (a tumour of the breast). C complained that A was told that they had a benign (non-cancerous) Phyllodes tumour when this was not the case. A later found out that the tumour had been malignant (cancerous). C also said that A was not offered radiotherapy (a treatment using high-energy radiation) or chemotherapy (a treatment where medicine is used to kill cancerous cells) following the Phyllodes tumour diagnosis, and that A was not appropriately monitored following the diagnosis.

We took independent advice from a consultant breast surgeon. We found that A was appropriately monitored following the diagnosis and it was reasonable that A was not offered radiotherapy or chemotherapy in the circumstances.

However, we also found that the clinic letters following A's surgery did not describe the Phyllodes tumour as malignant, and the size of the malignant Phyllodes tumour had not been documented in the multidisciplinary team notes. We upheld C's complaint on this basis.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to communicate reasonably with them regarding the Phyllodes tumour being malignant and for failing to record the size of the malignant Phyllodes tumour in the multidisciplinary team notes. 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 the type of Phyllodes tumour identified and such discussions should be clearly documented.
• The size of malignant Phyllodes tumours should be clearly documented in multidisciplinary team notes.

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, an advice and support worker, complained on behalf of their client (A). A was diagnosed with diabetic retinopathy (a complication of diabetes caused by high blood sugar levels damaging the back of the eye). As part of their treatment for this, A received intravitreal injections (this involves injection of medication into the vitreous – a jelly-like fluid at the back of the eye).

A received a number of these injections without incident, however, during one procedure, the tip of the needle touched the lens of A's right eye. This resulted in a traumatic cataract (a clouding of the lens, occurring after either blunt or penetrating trauma to the eye, that disrupts the lens fibres) that required further treatment. As a result of this, A had concerns about the administration of the injection. A felt the injection was not carried out appropriately or in line with relevant guidelines.

We took independent advice from a consultant ophthalmologist (a doctor who specialises in eye and vision care). We found that the complication experienced by A was uncommon but recognised. However, there was no evidence to indicate that the injury to A's eye was the result of failings on the part of the administration of the injection. Furthermore, such complications can occur despite the correct guidelines being followed and appropriate measurements being used. We agreed with the board's conclusion that there was no way to conclusively know what factors led to the injury to A's eye. As such, we did not uphold this complaint.

Summary

C, an advocacy and advice worker, complained on behalf of their client (A) regarding A's admission to Queen Elizabeth University Hospital. A is a diabetic and had a gastric band procedure (a band is used to reduce the stomach's size, so a smaller amount of food is required to result in feeling full) completed privately several years prior to admission. This had been successful, however, A was having difficulty eating and was admitted as an emergency. A's surgical band was deflated. Subsequently, A's blood sugar level was not stable. A considered this was not monitored properly and they were also unhappy with the feeding regime put in place. The emergency team refused to re-inflate the gastric band and referred A to the Exceptional Bariatric Review to discuss bands filled in the private sector. A was unhappy with this decision as they wanted the band to be reflated afterwards.

We considered that A was admitted as an emergency and it was reasonable to resolve the urgent situation by deflating the gastric band, as it was pressing on A's oesophagus. However, when the emergency had been resolved, any refilling of the band would not be regarded as a medical emergency. We found that the board followed their policy when referring A to the Exceptional Bariatric Review for bands filled in the private sector. We also noted that when A was admitted as an emergency their blood sugar levels were unstable but this was monitored and treated appropriately, as A did not have diabetic ketoacidosis (a potentially life threatening complication of diabetes, which happens when the body starts running out of insulin). We also found that the feeding regime put in place was reasonable and that A was appropriately referred so that future weight management could be discussed. We did not uphold this complaint.

Summary

C underwent right knee replacement surgery and complained about the care and treatment they received as they suffered severe pain and limited movement following surgery. It was C's understanding that something went wrong during the surgery and they also considered that the board had failed to provide the appropriate aftercare.

The board said there was no suggestion that anything went wrong during the surgery and noted that C underwent physiotherapy to help alleviate their pain.

We took independent advice from an orthopaedic surgeon (a surgeon specialising in the treatment of diseases and injuries of the musculoskeletal system). We found that there was a five degree misalignment in C's knee; however, it is unlikely that this would cause the pain C subsequently experienced. There are associated risks with the type of surgery C had and around 20 percent of patients may not experience a satisfactory outcome. There was no evidence that C's surgery was not carried out appropriately. We also found that the appropriate investigations were carried out to check that the knee joint was properly aligned post-surgery. As such, we did not uphold C's complaint.

Summary

C complained that their concerns about changes in their breast had not been investigated adequately by the board. As a consequence, there had been a delay in diagnosing C's breast cancer. C was also unhappy with the treatment that had been proposed for them. C believed that the board was unreasonably denying them breast surgery and was proposing to keep C on potentially harmful chemotherapy indefinitely. C sought a second opinion and did undergo breast surgery shortly afterwards. C believed this demonstrated the treatment proposed by the board was unreasonable.

We took independent advice from an appropriately qualified adviser. We found that the investigations carried out were reasonable. It had not been reasonable to inform C that their breast cancer was inoperable on the basis of the investigations that the board had carried out at that point. However, the treatment provided to C was reasonable and it was appropriate for the initial treatment to be chemotherapy, rather than proceeding directly to surgery. We did not uphold C's complaint.

Summary

C complained about the clinical care provided to their child (A) by the board, specifically, that a Chiari malformation (where the lower part of the brain pushes down into the spinal cord) was visible on a magnetic resonance imaging (MRI) scan performed by the board and that the abnormality was not noted until they insisted on a further MRI scan.

A suffered from a number of symptoms including headaches, tinnitus (ringing or buzzing in the ears), vertigo (a sensation of loss of balance or that objects around you are spinning) and drop attacks (sudden falls to the ground) for a number of years.

In relation to the reporting of the MRI scan, the board considered it was a miss of an incidental finding and apologised for the matter in retrospect.

We took independent advice from a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). Whilst we found that it was reasonable to ask only about a possible tumour, we considered that it was unreasonable that the radiology report did not report on the cerebellar tonsillar protrusion (a type of brain herniation) or indicate the presence of Chiari malformation. We also noted that the type of Chiari malformation A had (Chiari I) does not necessarily produce symptoms, but good practice would have been to record this finding and suggest review by a neurosurgeon, which did not happen in this case. We upheld this aspect of C's complaint.

C also complained about the communication that occurred with an ear, nose and throat (ENT) consultant. We took independent advice from an ENT consultant. We found that it would not be reasonable to expect an ENT clinician to recognise the Chiari malformation when the radiologist did not. However, we found that it was unreasonable that there was no record of discussions with A or C about the third scan being arranged, or discussions about medications. The board accepted that there had been failings in communication with the family and they took steps to address the matter. We upheld this aspect of the complaint, but made no further recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for not having referred in the radiology report to the cerebellar tonsillar protrusion, or indicate the presence of a Chiari malformation. 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:

• Radiological reports should be accurate and reasonable.

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 sibling (A) after A was admitted to hospital with a history of progressive vomiting and nausea. The dietetics team (specialists in the scientific study of the food that people eat and its effects on health) asked for A to be prescribed thiamine (vitamin B1) for malnutrition as A had recently lost ten percent of their body weight. The prescription was not made and A did not receive the thiamine supplements. A was discharged several days later as their symptoms had improved and investigations had been generally reassuring. Several weeks later, A suffered a collapse and was readmitted to hospital with confusion and reduced mobility. After extensive investigations, A was diagnosed with Wernicke's encephalopathy (a condition which affects the brain, caused by lack of thiamine). C complained that the board had failed to provide reasonable care and treatment to A in relation to the failure to prescribe thiamine, and that discharging A had been unreasonable.

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 noted that the board had previously acknowledged that there was a failure to give A thiamine when originally recommended by the dietetic team, and they had apologised for this. They had also implemented a ward round checklist to prevent similar failings recurring. However, based on the advice we received, we were concerned that the board had not fully considered or accepted the potential impact of this failure, as we considered that thiamine supplements may have at the very least lessened the severity of the Wernicke's that subsequently developed. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to provide A with thiamine, and for failing to acknowledge the potential impact of this. 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:

• Staff should be aware of the potential impact of thiamine deficiency and the manner in which Wernicke's encephalopathy develops.

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 been in contact with a number of specialists at the health board as C suspected they were symptomatic of lung cancer. C said that a tumour in their lung was visible from a number of tests carried out by hospital specialists, but that this was unreasonably missed. C also said that treatment decisions and management were not reasonable and that the failure to diagnose them with lung cancer within a reasonable time had catastrophic consequences for their prognosis. C was also concerned about the way the health board dealt with their complaint.

We took independent advice from three advisers: from a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans), a respiratory physician (a doctor who specialises in treating and managing patients with conditions affecting their lungs) and from an orthopaedic specialist (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that C's treatment was reasonable. C was regularly reviewed and their antibiotics were changed in order to try and improve their outcome.

However, we found that there was a significant delay in the diagnosis of lung cancer resulting from an unreasonable failure of radiological interpretation which lead to significant injustice to C; this failure would shorten C's life. We also found an unreasonable failure to follow up test results or to carry out a further scan, although we concluded that in themselves this would not have changed the outcome for C.

In relation to the standard of respiratory care and treatment provided, we found that the diagnostic process and treatment decisions were reasonable.

Finally, we found significant failings in the health board's investigation of C's complaint. While the health board identified radiological errors, they did not apologise for these or explain how they occurred and what action the health board were taking to ensure they did not happen again, nor was there any consideration of the impact of these errors on C's prognosis and treatment decisions. We upheld three complaints out of four.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation and inform C of what and how actions will be taken to stop a future reoccurrence. 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:

• Carry out an audit of x-rays and scans taken between a specified time-period to ensure there is no systemic issue which may have affected other patients.
• Ensure that test results are followed up appropriately.
• Feedback the findings of our investigation in relation to the complaint handling failures to relevant staff for them to reflect on.
• Feedback the findings of our investigation in relation to the failure of radiological interpretation to relevant staff for them to reflect on.
• Review the complaint handling failures to ascertain: how and why the failures occurred; any training needs; and what actions will be taken to stop a future reoccurrence.
• Review the failure of radiological interpretation to ascertain how and why the failures occurred and what actions will be taken to stop a future reoccurrence and inform this office of the results.

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 by the Golden Jubilee National Hospital. C underwent knee arthroscopy (a type of keyhole surgery used to diagnose and treat joint problems). Around two weeks later, C developed what was considered to be a surface infection, for which they were prescribed antibiotics and given another appointment for later in the week. Two days later, C attended another hospital's emergency department with pain and swelling. They required further surgery to wash out the joint. C complained that the decision to carry out the knee arthroscopy had been unreasonable, and that the care and treatment provided when they had an infection was unreasonable.

We took independent advice from an orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the decision to carry out an arthroscopy on C's knee had been unreasonable, as C had severe arthritis and carrying out the surgery was contrary to British Medical Journal Clinical Practice Guidelines. We upheld this aspect of C's complaint.

In relation to C's treatment when they had an infection, we found that it was reasonable for the surgeon to consider this to be a superficial wound infection rather than a deep wound infection, and the care and treatment provided for this was 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 unreasonably carrying out a knee arthroscopy. 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:

• Knee arthroscopies should not be carried out in patients such as C with degenerative knee disease, in line with relevant clinical guidelines.

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.