Health

Summary

C, a patient adviser, complained on behalf of their client (A) in relation to the care and treatment provided to A's child (B) by the board. B was diagnosed with a type of slow growing brain tumour and subsequently underwent a surgical procedure to treat build-up of fluid in the brain. B experienced a neurological deficit following the procedure and the surgeons identified that the burr hole (a small hole drilled into the skull) was not placed at the intended site. Over the following months, the neurological deficit improved but B continued to experience severe headaches following the procedure. Follow-up care was provided by paediatric oncology (specialists in treating children with cancer) and paediatric neurology (specialists in treating children with disorders of the nervous system) as well as other specialties over the following years.

We took independent advice from a consultant paediatric neurosurgeon and a consultant paediatric neurologist.

Firstly, C raised concern that the board did not obtain informed consent for the surgery and that the surgery was not performed to a reasonable standard. We found that there was limited reference to complications within the consent form and the written notes, whilst a number of known serious complications were not included in the consent form. We also found that the incorrect placement of the burr hole was unreasonable and that this likely caused the neurological deficit that B experienced. We upheld these aspects of C's complaint.

C also complained that the board did not manage B's pain reasonably following the surgery. We found that this aspect of B's care had been reasonable, with close involvement from both a consultant paediatric oncologist and a consultant paediatric neurologist over a number of years. We did not uphold this aspect of C's complaint.

Finally, C raised concern about the communication between the board and the family about B's care. We found that the documentation of discussion with B's parents about the surgical complication was poor. We found that the communication in relation to B's headaches was, on balance, reasonable. However, we noted that there should have been better communication from the paediatric oncology team. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B and B's parents for the failings identified in the consent process, in the surgical procedure and in communication with the family. 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:

• Adequate systems should be in place to ensure that technical errors are minimised.
• In accordance with the professional duty of candour, health professionals must tell the patient (or, where appropriate, the patient's advocate, carer or family) when something has gone wrong and apologise for what happened. This should be clearly documented.
• Informed consent should be obtained in accordance with the General Medical Council's guidance on this matter.

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 adult child (A) had anxiety and a functional neurological illness (a condition in which patients experience neurological symptoms such as weakness, movement disorders, sensory symptoms and blackouts). One morning A was found to be anxious and unwell. A's other parent (B) thought that it appeared different to A's previous episodes and called the GP who visited A at home.

The GP believed that A should be admitted to hospital and called 999. An ambulance crew attended the scene. There was some discussion between the GP and the hospital about which department A should be admitted to; the Mental Health Unit or the Clinical Assessment Unit. The ambulance crew transported A to hospital where A was quickly assessed and taken to the Intensive Care Unit. A died later that day.

C complained that the GP had not properly assessed A, they had not taken blood pressure readings or their temperature. C said that the GP assessed A through the prism of mental health and had not properly considered whether there could be another cause to their presentation, which was different from previous ones.

We took independent advice from a GP. We found that it was appropriate for the GP to consider A's prior medical history when assessing their condition. We found that the GP correctly identified that assessment at hospital was needed, recognising the seriousness of A's condition.

On the basis of information available to the GP at the time, their assessment and conclusions were reasonable. Therefore, we did not uphold the complaint.

Summary

C complained about a psychiatric consultation at Falkirk Community Hospital. They complained that they did not receive adequate support from the psychiatrist and that the psychiatrist made inappropriate comments regarding the impact of suicide on others and the best way to complete suicide. We took independent advice from a consultant psychiatrist. It was not possible to confirm from the notes the way the psychiatrist communicated with C or exactly what was discussed surrounding suicide. The board explained that it was the psychiatrist's normal practice to discuss the impact of suicide on others but refuted that C was advised of the best way to take their own life. We considered that the psychiatrist carried out a reasonable assessment and proposed an appropriate management plan. We did not uphold this complaint.

C also complained that a board run GP practice refused to continue their prescription for gabapentin (an anticonvulsant medication primarily used to treat partial seizures and neuropathic pain) until C had been seen by the psychiatrist. This medication had been prescribed overseas and C noted that it was for restless leg syndrome (RLS) and not a psychological condition. The board explained that gabapentin is a controlled drug in the UK which can only be prescribed in specific circumstances and with specialist input. They noted it is unlicensed for RLS. We took independent advice from a GP, who noted that gabapentin can be prescribed 'off-label' to treat RLS and they saw no reason for changing this if C had been taking it with good effect and was established on a reasonable dose. However, if the practice had concerns and wished to change this, it should have been gradually reduced and not stopped suddenly. We concluded that it was unreasonable to have refused to prescribe C gabapentin pending a psychiatric review. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the stoppage of their gabapentin without a reduction regime. 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 ensure the practice GPs familiarise themselves with gabapentin reduction regimes and the indications for the same.

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 consent process and the standard of surgery for a procedure they had received from the board. C was listed for a surgical procedure with the aim of removing a stoma (an opening in the abdomen formed during a colostomy procedure) and a para-stomal hernia (a weakness in the abdominal wall beside a stoma which allows the bowel to protrude outwards). The surgeon was unable to safely perform the procedure as planned and the decision was made to create a new stoma site. C experienced complications with the wound following surgery and was unhappy with the outcome.

We took independent advice from a consultant colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We found that C should have been informed about the risk that it might not be possible to complete the intended procedure successfully and the implications of this. In the absence of evidence that C was informed of this, we concluded that the board had failed to obtain appropriate consent for the procedure, in line with recognised guidance. We upheld this aspect of C's complaint.

In relation to the surgical procedure, we found that this was performed to a reasonable standard and the decisions made by the surgeon during the operation were reasonable. Given the findings, we did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that the risks for the surgical procedure were not fully outlined as part of the consent process. 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:

• A patient's medical history should be considered to anticipate difficulties in a procedure and the likely scenarios that could emerge. Patients should receive information about the risks in a way they can understand (including side effects; complications; or failure of an intervention to achieve the desired aim), taking into account the information they want or need to know. This should be fully documented.

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 matters relating to their previous GP practice. C had been removed from the practice list as in the practice's view there had been a complete breakdown in the doctor/patient relationship due to the way C was using a prescribed antibiotic medication. The practice wrote to C to inform them of their decision.

C had concerns about the practice's decision to remove them from the list. We found that the practice had failed to provide C with a warning before removing them from the practice list. Therefore, we upheld this aspect of the complaint.

C was also unhappy with the factual accuracy of a letter sent by the practice regarding the removal decision. We did not find that the practice's letter contained inaccuracies and we were unable to conclude that it was unreasonable. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to issue a warning before removing C from their practice list. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Reconsider any application to register received from C.

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

• A breakdown in a doctor/patient relationship should be managed in line with General Medical Council guidance and the relevant legislation.

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 practice failed to provide them with effective treatment for a skin complaint and that they waited an unreasonable length of time before they saw a doctor.

We took independent advice from a nurse adviser and a GP adviser. C had first attended two nurse consultations, a week apart, as they had developed an itchy rash on their back. We noted that the initial working diagnoses (insect bites/fungal infection) and the care and treatment provided at this point was reasonable. Ten days after C's first consultation, they contacted the practice again. As the triage telephone call mentioned 'shingles' as another possible diagnosis, a referral to see a GP should have been made at this time. However, C was given an appointment with an advanced nurse practitioner. Although C was being treated with an allergy tablet, there was no documented working diagnosis of what was causing the itch. We found that the management of C at this time was not reasonable.

C contacted the practice again the following day and requested to be seen by a GP. This was the fourth time C had contact with the practice in eleven days since the onset of the rash, which was getting worse and becoming painful. Although the advanced paramedic practitioner who saw C on this occasion sought advice of a GP regarding treatment, we considered that it was unreasonable that C was not referred to be seen by a GP at this time.

C made a further request for a GP appointment two weeks later and again was given an appointment with an advanced paramedic practitioner. We found that this was unreasonable given that this was C's second request for a GP appointment, they had seen nurse and paramedic practitioners four times over a period of several weeks and had attended the out-of-hours service, during which time their rash was getting worse/not responding to prescribed treatment and was painful.

Due to their ongoing symptoms, C attended again at the out-of-hours service when they were prescribed an oral steroid and advised to contact their GP to expedite a dermatology (diseases of the skin, hair and nails) appointment as soon as possible. At this time, C had still not seen a GP in the practice and we considered this to be unreasonable. When C eventually saw a GP, an urgent referral to dermatology was made. The care and treatment provided by the GP at this time was reasonable.

Taking into account all of the evidence and the advice we received, we found that the practice failed to provide C with reasonable care and treatment. As such, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to have an appropriate management plan in place and for failing to refer C to be seen by a GP earlier. 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:

• Where a patient presents on several occasions with an acute condition that is not responding to treatment, an appropriate management plan should be in place. Where a patient has seen advanced practitioners on two occasions and requires to be seen a third time with the same acute condition, consideration should be given to having a GP review the patient.

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 spouse (A) received care and treatment from the board for a recurrence of bowel cancer. C complained that the communication and actions by the board in relation to that were unreasonable.

C complained that the board failed to provide reasonable treatment to A. We took independent advice from a senior clinical oncologist (a doctor who specialises in the diagnosis and treatment of cancer). We found that the treatment offered to A was reasonable and in line with guidance. We did not uphold the complaint.

C complained that the board failed to provide reasonable care to A. We found that the board had acknowledged there were some failings relating to staff responding to care requests and there were challenges when a procedure was undertaken. Overall we found that while there were failings in specific instances, the care provided over the entire period was reasonable. On balance, we did not uphold the complaint.

C complained that the board failed to reasonably communicate with A and C in relation to A's diagnosis and the potential risks of treatment. We found, based on the written records available, that the communication was reasonable, noting that the written records could not illustrate the level of empathy exhibited by clinicians. The written records did demonstrate that the risks relating to treatment were discussed. We did not uphold the complaint.

Summary

C complained about their urology care (the branch of medicine and physiology concerned with the function and disorders of the urinary system) and treatment at Borders General Hospital. C has a complex past urological and surgical history including a total cystectomy (bladder removal), and was referred to urology with ongoing pain and discomfort around their stoma region (an opening in the abdomen formed during a colostomy procedure). C complained that the urologist did not see them and that they were instead seen by a general surgical registrar who failed to identify symptoms of a kidney stone. C subsequently became very unwell and was admitted to hospital with an obstructed infected kidney.

In their response to C's complaint, the board confirmed that the urologist felt it best for C to be seen by the consultant general surgeon who had carried out their most recent hernia (a weakness in the abdominal wall beside a stoma which allows the bowel to protrude outwards) repair surgery. They noted that, when C was then assessed by the surgical registrar, they did not have any specific symptoms which would have indicated the presence of a kidney stone.

We took independent medical advice from a consultant urological surgeon. We found that it was reasonable for C's clinical assessment to have taken place with either the surgical or urological consultant team. We, therefore, did not uphold C's complaint about a lack of urological review. We considered that C was appropriately assessed by the surgical registrar, and there was no clinical evidence at that time to indicate the presence of a kidney stone. We did not uphold C's complaint about a failure to diagnose their kidney stone. We noted, however, that C should have been seen by the consultant general surgeon, rather than a surgical trainee, in light of their complex history. We fed this back to the board.

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.