Health

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.

Summary

C complained to us about the care and treatment their spouse (A) received at the Golden Jubilee National Hospital. A was referred to the hospital after being diagnosed with aortic stenosis (where a valve has narrowed and is restricting blood flow).

We took independent advice from advisers both in cardiology (studies of diseases and abnormalities of the heart) and in cardiology nursing.

C raised concern that A's angiogram (a type of x-ray that uses dye to look at blood vessels) was not carried out reasonably, including the aftercare. We found that A's angiogram was carried out in a reasonable manner and the aftercare was appropriate. We did not uphold this aspect of C's complaint.

C also raised concern about an unreasonable delay in arranging A's heart surgery. We found that the hospital carried out appropriate tests to decide whether to list A for heart surgery. We also found that the hospital's decision not to proceed with heart surgery was reasonable, due to the risks involved from A's other health conditions. We did not uphold this aspect of the complaint.

Summary

C, an advice and support worker, complained on behalf of their client (A) in relation to the care and treatment provided to A by the board.

A attended Forth Valley Royal Hospital as they had suffered a myocardial infarction (heart attack - when blood flow decreases or stops to a part of the heart, causing damage to the heart muscle) the previous week. A presented to the hospital complaining of pain and swelling affecting their wrist. A was examined and treated for this.

A said that the board failed to provide reasonable care and treatment to them as they were not treated appropriately and questioned whether alternative treatments could have been offered. A also said that it took several visits to A&E to be treated appropriately and that they were not referred to a specialist following that first visit.

We took independent advice from an appropriately qualified adviser with expertise in emergency medicine. We did not observe any concerns with the care and treatment that A received and concluded that assessment, treatment and advice given were reasonable. Therefore, we did not uphold C's complaint.

Summary

C raised numerous concerns and complaints about repeated errors with the issuing of Movelat (pain relieving gel). C maintained the gel should be issued to them weekly but when submitting requests to receive the gel, they experienced difficulties. C received mixed responses as to why the gel was not issued. Some of the replies issued indicated the gel should be issued monthly. Other replies acknowledged that the gel should be issued weekly and explanations were offered for the error.

The evidence available confirmed that the gel was to be prescribed weekly to C. Despite this, C had to continually raise concerns in relation to ongoing errors with the prescribing frequency of the medication. It took some time before preventative steps were taken, by way of a note that was added to C's record confirming that the frequency of the prescription for the gel should not be changed.

We accepted that any delay in issuing the gel will not have had serious consequence for C, and we recognised the actions taken to minimise errors with the prescribing frequency of the gel. However, we found the administrative handling of the matter was poor. C had to unnecessarily submit repeated feedback and complaints only to receive mixed replies and for the problem with the prescribing frequency to continue longer than it needed to. As such, we upheld this aspect of the complaint.

C also complained about the decision taken by the healthcare team to discontinue a prescription for Difflam spray (an anti-inflammatory spray used to treat many painful conditions of the mouth or throat). It was explained to C that the throat spray was a short-term treatment for symptomatic relief of painful conditions of the mouth. It was noted that C had been taking the spray for several months, but there was no record to confirm the reason for that. C was reviewed by the dentist, who found no evidence of ulcers. The dentist had initially agreed to reinstate the spray but it was discontinued following a further discussion with an advanced nurse practitioner due to lack of mouth ulcers.

We took independent advice from an appropriately qualified clinical adviser, We found that the decision to stop the mouth spray had been taken in line with good practice as set out by the General Medical Council. As such, 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 issue the pain relieving gel weekly, as per their prescription. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for the unnecessary time and trouble they had to go to in an effort to get clear explanations and replies in relation to the prescribing errors with the pain relieving gel, and to get the issue resolved.

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 spouse (A) about the treatment provided to them. A had a history of cancer and attended the practice with urinary symptoms. A was later diagnosed with bowel cancer which had metastasised (spread to other parts of the body). C complained that the practice's response to A's symptoms, and the length of time it took for A's cancer to be diagnosed, were unreasonable.

We took independent advice from a GP. We considered that A's symptoms were reasonably investigated, with appropriately prioritised referrals being actioned in a timely manner. A's history of cancer was considered when assessing their symptoms. A's symptoms initially aligned with a benign (non-cancerous) condition. When A's presentation changed, appropriate steps were taken, with further investigation and referrals to secondary care. A's pain was reasonably managed. Therefore, we did not uphold the complaint.

Summary

C was admitted to hospital for an elective hernia repair. The procedure was said to have gone well and it was agreed that C could be discharged home. Before leaving hospital, C took a stroke (a serious medical condition that happens when the blood supply to part of the brain is cut off. Strokes are a medical emergency and urgent treatment is essential). In C's case, it was thought they had experienced a reaction to the medications they had been prescribed and it was deemed that they could be discharged from hospital. Once at home, C was reviewed by their GP, who arranged for them to return to hospital for further tests. Those tests confirmed that C had had a stroke prior to being discharged from hospital.

We took independent advice from an appropriately qualified clinical adviser. We found that the board failed to document the assessment of C that was undertaken prior to them being allowed to return home. Without that evidence, we were unable to determine whether the assessment of C's symptoms was of a reasonable quality. We reached the view that the board unreasonably failed to diagnose that C had suffered a stroke and upheld the complaint.

In addition, we found that the board's response to C's complaint was too brief, and lacked sufficient detail. There was little recognition that a significant diagnostic error had occurred, or the effect this may have had on C. The board's investigation and response did not note or disclose to C that there was no documentation in relation to this aspect of their care. The response also lacked appropriate detail in relation to the relevant discussions held as a result of C raising their complaint. We made recommendations to the board concerning these points.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to diagnose that they had suffered a stroke prior to being discharged home; assess them in sufficient detail; and record details of the assessment in their notes, and discharge letter. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The board should write to C clarifying what action was taken once the educational supervisor was informed of the matter. The response should also provide further feedback in relation to the discussion held at the general surgery meeting, and what actions may have been agreed.

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 spouse (A) about the mental health care and treatment provided to A by the board. A has ongoing mental health difficulties and has been supported by both psychiatry and community psychiatric nurses, as well as more recently having psychology input.

We took independent advice from a psychiatrist (a doctor who specialises in the diagnosis, treatment and prevention of mental ill health conditions). We found that, whilst there were aspects of care and treatment that were reasonable, there had been a delay in A being given a psychiatry appointment. We upheld the complaint on this basis; however, as the board had previously acknowledged and apologised for this failing, we did not make any further recommendations.

Summary

C suffers from severe joint and musculoskeletal (relating to the muscles and skeleton) pain throughout their body. C complained that the board did not reasonably test C to establish the appropriate level of pain treatment they required. C wanted medication for pain to be administered by an intrathecal pump (a medical device used to deliver very small quantities of medications to the spinal fluid) and by trigger-point injections (a procedure used to treat painful areas of muscle that contain trigger points, or knots of muscle that form when muscles do not relax). The board did not consider this to be appropriate.

We considered that the board was aware of the level of pain experienced by C and that the pain management had been reasonable. We found that an intrathecal pump is usually used to target pain in a specific area for cancer patients or in palliative care, rather than where pain is benign (not directly linked to another medical condition) and widespread. We found that an implant can cause infection and that this increases over time and therefore the risk of use is lower for those in receipt of palliative care. We also found that if pain is not responsive to opioids (a type of pain relief) then delivery of opioids by this method is not likely to be effective. We also found that trigger point injections offer short-term relief and their effectiveness reduces when repeated. We therefore agreed with the board that these treatments were not appropriate for C. We did not uphold this complaint.