Health

Summary

C fell and injured their head, requiring emergency surgery and the removal and replacement of part of their skull. Tayside NHS board carried out the surgeries and provided rehabilitative care. C complained that the board failed to properly insert the ceramic bone replacing the portion of skull taken out, causing disfigurement. C was also not satisfied with the explanations given by the board in relation to the care provided.

We took independent advice from a consultant neurosurgeon (a surgeon specialising in surgery of the brain and nervous system). We found that the board provided reasonable treatment to C. C’s injuries required two emergency operations, both of which were reasonably carried out. The board provided a custom-made plate to replace the portion of the skull lost due to the head injury. The surgeries and follow-up care provided to C were of an extremely high standard. While there was a complication with one of the surgeries, this was a known complication for cranial surgery which the board accepted and apologised for. After the operations were completed, the board provided rehabilitation to C through multiple rehabilitation schemes. This was reasonable. As such, we did not uphold this aspect of C's complaint.

We also considered C’s complaints that the board had failed to provide a reasonable explanation about the treatment they received. We found the board provided reasonable explanations to C about the treatment they provided. Clinicians spoke with C on multiple occasions to discuss the outcomes of the surgeries. The board took account of C’s cognitive difficulties when communicating with them and exceeded the level of standard care required in terms of communication. The board’s response to C’s complaint explained the outcome of C’s surgeries including the impact on C’s facial appearance. This was reasonable. As such we did not uphold this aspect of the complaint.

Summary

C complained about the treatment their late spouse (A) received from Tayside NHS board. Following a fall, A required emergency hip replacement surgery. A developed a severe infection in their wound following the surgery and later died as a result of this infections. C complained that the board inappropriately ignored issues with A’s stomach when prescribing antibiotics. C also considered that A was required to attend hospital appointments unnecessarily when their condition became untreatable. C stated that at a meeting to discuss their complaint after A’s death the board told them that A had not been expected to live. C said they were shocked and had not been told this before.

The board stated A’s treatment had been reasonable. Staff had responded appropriately to A’s serious infection. Although every step had been taken to avoid infection, these did occur. A’s condition had been regularly reviewed and advice taken from microbiology specialists to try and optimise A’s treatment.

We took independent medical advice from a orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found A’s treatment was reasonable. They were regularly reviewed and their antibiotics were changed in order to try and improve their outcome. In addition, we noted that A’s condition was such that it was not unreasonable for them to have their wound dressed as an out-patient. Therefore, we did not uphold C’s complaints.

Summary

C, an advice and support service worker, complained on behalf of their client (A) regarding care and treatment A received from the board. A presented to University Hospital Monklands with abdominal pain, which had been treated as a urinary infection. It was thought that the symptoms were related to their kidneys. A had a scan days later and as a result was diagnosed as having a twisted right ovarian cyst which required surgery. C complained that there had been a misdiagnosis and delay in carrying out a scan. They questioned whether the ovary would not have needed to be removed had the correct diagnosis been made earlier. C also complained that A’s mobility and pain were not properly assessed, and compression stockings were not provided.

In responding to the complaint, the board apologised that there had been a breakdown in communication regarding the scan and advised that this would be discussed with the doctor in further detail. In terms of the nursing care provided, the board did not identify any failings.

We took independent advice from a consultant general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus) and from a registered nurse. In terms of the medical care, we found that A’s ongoing pain three days after being treated for urine infection was uncommon and that a diagnosis of kidney stones or another cause of pain should have been considered. We considered that a scan should have been carried out on the day it was originally planned and it was unreasonable care that this did not happen. However, we did not consider that A’s outcome of undergoing surgery and having an ovary removed would have been affected by the delay in the scan. Nevertheless, we found that the delay resulted in A being in pain for longer and acknowledged that this was distressing for them. We upheld this complaint.

In terms of the nursing care, we found it was reasonable not to have provided A with compression stockings. However, we considered there were failings in a mobility assessment not being carried out, and there was no clear care plan for their persistent and unresolved pain. Had there been so, this may have led to escalation to medical staff; a review of their pain; and expedited some of tests, if it was recognised pain was becoming difficult to manage in the context of an undiagnosed cause. For these reasons, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the following aspects of their care: that there was no differential diagnosis or a plan on management clearly recorded; that there was no medical review of A’ pain and observations documented; that there was no explanation about why the original plan for a CT scan was changed to an ultrasound scan and then changed back; that there was a delay in performing a CT scan; and that A’s mobility was not reasonably assessed or at least documented. 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:

• Clearer record for pain relief and management is required to accurately assess pain with escalation to medical staff as appropriate.
• Documentation on rounds should provide adequate reflection of clinical examination, review of observations, possible diagnosis, and plan of management.
• Nursing staff should ensure, where relevant, a patient’s mobility is assessed and documented.

Summary

C complained on behalf of their partner (A) after A's leg was amputated above the knee without C’s consent. We did not uphold this complaint as there was evidence of discussion with A prior to the operation and a consent form had been signed by A.

C also complained that the board unreasonably amputated A’s leg above the knee when a toe amputation would have been sufficient. A’s leg was vascularised down to their knee and there were significant problems with A’s foot. A toe amputation would not have been sufficient. It was reasonable to amputate A’s leg rather than conduct by-pass surgery. We did not uphold this aspect of the complaint.

C also complained that a Do Not Attempt Cardia Pulmonary Resuscitation (DNACPR) was put in place while A was unable to consent to it and that A was later discharged with this. We noted that there were issues relating to retaining a copy of the DNACPR on file, it but as consent was obtained once A was able to consent, we did not uphold this aspect of the complaint.

C also complained that the board changed their response to the complaint regarding consent to A’s amputation. The board had originally stated that A had been unable to consent to the amputation at the time and that it was performed out of medical necessity; however, later they located documentation to show that A had actually consented. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to conduct an accurate investigation 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.

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

• Ensure clinical staff who have been asked to provide information relating to a complaint to the complaints team, check their understanding against contemporaneous clinical records, when giving statements for internal investigations. Ensure the complaints team ask staff feeding back comments if they have checked their understanding against contemporaneous 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 complained on behalf of their sibling (A) following A's contact with a health board’s mental health service when they were in crisis. C was concerned about the standard of care and treatment provided to A. C’s concerns were wide-ranging and covered numerous aspects of the provision of care and treatment. C said this included repeated, unreasonable, failures by staff to recognise and diagnose A with psychosis and paranoia, to prescribe appropriate medication, to communicate adequately with A or their family or both, adequately supervise A, to agree a care plan and put in place appropriate discharge care, and to admit A as an in-patient at each emergency department attendance.

We took independent advice from a consultant psychiatrist and from a mental health nurse. We found that the diagnosis was appropriately assessed and reasonable conclusions reached on management and treatment of A. However, we also noted some concerns about aspects of communication with A and their family and found significant shortcomings in relation to record-keeping about a discharge from one hospital admission in particular. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation. 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:

• Ensure relevant clinical staff at Wishaw General Hospital are aware of their responsibility to document patient management decisions in relation to General Medical Council Good Medical Practice 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’s child (A) was referred to have a tonsillectomy (surgical removal of the tonsils) and grommets (a small tube inserted in the eardrum to drain fluid) inserted as they had been experiencing seizures and recurrent ear infections. On the day of surgery, the surgeon decided not to insert grommets as A's ears were healthy and there was potential for an unnecessary intervention. C complained that the surgeon failed to carry out the agreed surgery.

We took independent advice from an ear, nose and throat consultant. We found that it was appropriate for the surgeon to make a clinical judgement on the day of surgery based on the clinical presentation of the child. We noted that the clinical decision was supported by clinical research and it was therefore reasonable. As such, we did not uphold the complaint.

Summary

C complained to us that staff from Greater Glasgow and Clyde NHS board had delayed in identifying that they had compartment syndrome (a painful and potentially serious condition caused by bleeding or swelling within an enclosed bundle of muscles – known as a muscle compartment). C was admitted to Glasgow Royal Infirmary after a fall in their garden where they sustained a tibial plateau fracture (a break in the upper part of the shin bone). They had surgery for this and the board stated that there was no evidence of compartment syndrome at that time. C continued to suffer problems including wound leak, foot drop and numbness in their leg. They were taken back to theatre and it was identified that they had developed compartment syndrome of the muscles of the anterior (front) compartment of their lower right leg. This has had a significant impact on C’s life.

We took independent advice from a trauma and orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that, given C’s high risk injury, the symptoms of excess pain and numbness and the signs of reduced sensation and weakness, it was unreasonable for the board not to have either measured the compartment pressure or performed fasciotomies (the skin and fascial compartment are cut open so that the compartment pressure is relieved). This should have occurred after C’s operation and it was unreasonable for C to have been discharged home without this being carried out. If compartment syndrome had been recognised early, and swift decompression performed, on balance, the extent of the surgery performed subsequently would not have had to be so severe and the functional outcome not as bad. Therefore, we upheld this complaint.

However, consultants from the board had already met C to apologise that the onset of compartment syndrome was not identified earlier. The board had also outlined further action they had taken to prevent this issue recurring. In view of this, we did not make any recommendations to the board.

Summary

C, an advocate, complained on behalf of their client (A). The complaint related to an incident that occurred when A was a patient in hospital. After receiving treatment in hospital, A was taken to a single room to recover. Another patient entered A’s room several times in an erratic and alarming manner before being removed by nursing staff. However, during the night, the other patient entered A’s room again and sexually assaulted them. When nursing staff became aware of A shouting, they removed the other patient from the room. After this, the other patient did not interact with A again and A later reported the incident to the police.

C complained as A felt that not enough was done to prevent the other patient from interacting with A and ultimately sexually assaulting them. In addition to this, C complained about the board's handling of A’s complaint.

We took independent advice from a nurse. We found that nursing staff acted reasonably, both before and after the incident. We acknowledged that A had been through an extremely distressing experience, however, based on the circumstances at the time, and in the context of a hospital environment, we concluded that there was no indication that nursing staff failed to carry out any actions that they should have done. As such, we did not uphold this aspect of the complaint.

In respect of how the board handled A’s complaint, we were satisfied that this was done in a reasonable and appropriate manner. From our review of the evidence, it appeared that the board did not receive documentation from A’s advocate. This meant that the board communicated directly with A and appeared to have been genuinely unaware that an advocacy service was assisting A. The board had also arranged to provide the stage 2 response to A at a home visit. While we appreciated that it would have been helpful for A to have sight of the board’s stage 2 response before the visit took place, we did not consider this amounted to a significant failing on the board’s part. Overall, we considered the evidence suggested that the board took this complaint very seriously and that they made a genuine attempt to handle it in a sensitive and person-centred manner. As such, we did not uphold this aspect of the complaint.

Summary

C complained about the care their partner (A) received at an orthopaedic clinic in Inverclyde Royal Hospital. A was assessed for knee pain by an advanced physiotherapy practitioner (APP). C complained that the APP incorrectly diagnosed A as having a degenerative lateral meniscal tear (torn cartilage between the thigh bone and shin bone) and mild osteoarthritis (chronic breakdown of cartilage in the joints leading to pain, stiffness and swelling) and unreasonably decided to manage the condition by avoiding invasive measures as opposed to surgically. An orthopaedic review and scan the following year found no evidence of a tear. A ultimately required partial knee replacement surgery. C complained that the initial misdiagnosis and management plan contributed to the subsequent deterioration.

In responding to the complaint, the board said that the APP gave appropriate advice and treatment in keeping with the clinical picture at the time. They noted there was a subsequent deterioration of A’s knee over the following year.

We took advice from a consultant physiotherapist (a person qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise), who considered that the APP carried out an appropriate examination and reached a reasonable conclusion as to the cause of A’s knee pain. There could have been a tear that did not show up on the MRI scan. We also noted the x-ray evidence showed that A had some arthritic change in their knee. There wasn’t sufficient evidence to say what the primary cause of A’s knee pain was, however, the treatment plan would have been the same regardless. We found that the decision to recommend conservative management was reasonable and in keeping with relevant guidelines. We did not uphold this complaint.

Summary

C complained about the care their parent (A) received during an admission to Queen Elizabeth University Hospital. A was admitted following a fall at home and had a further fall in hospital, resulting in a fracture to their right shoulder. C complained that A’s fall in hospital could have been prevented, if ward staff had followed the board’s falls prevention protocols, had correctly assessed A’s risk of falls and had taken appropriate measures to ensure their safety on the ward.

We took independent advice from a nurse. We found the record-keeping was unreasonable and not of the required standard in relation to the assessment and prevention of A’s fall and also the incident reporting of the fall. The falls risk assessment was completed within the stipulated policy timescale of 24 hours from admission. However, the decision not to undertake this during the immediate admission appeared to have been taken by a student nurse without oversight from a registered nurse. We found no evidence to confirm what interventions, besides bed rails, had been put in place to prevent A from falling.

The incident report of the fall lacked clarity and consistency. The incident was initially miscategorised as minor and was not updated to serious when the fracture was diagnosed, so the relevant escalation and review was not triggered. The board indicated that a review had subsequently taken place, but we saw no evidence of this or of the learning and improvement derived from it. The adverse event review findings were not discussed or shared with C, as they should have been in keeping with national Being Open in NHS Scotland guidance. We upheld this complaint. We also found that the board did not respond to C’s complaints in a timely and robust manner.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the identified inadequacies in record-keeping surrounding A’s fall; for the lack of supervision of the student nurse who assessed A; for failing to share with C a copy of their adverse event review; and failing to investigate C's complaint in a timely and robust manner. 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 their performance with regard to the Being Open principles to ensure that appropriate systems are in place to share the outcome of incident reviews with patients and family members.
• The board should review their procedures to ensure accurate reporting, and appropriate review and investigation, of adverse events.
• The board should review their record-keeping in this case to ensure that nursing staff are meeting the standards required of them in this respect.
• The board should take steps to ensure that appropriate supervision of student nurses is in place.

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.