Health

Summary

C complained that the board failed properly to investigate the causes of their neck and shoulder pain. As a result, they said that they experienced up to 20 migraines a month and spent a large part of time in bed. C said that they regularly asked for an x-ray but were told that it would not be appropriate and were prescribed a number of medications and botox, none of which had effect. Because they were struggling with their quality of life, C attended a private chiropractor (a person who treats diseases by pressing a person's joints, especially those in the back) who took x-rays which revealed that the vertebrae at the top of their spine were out of alignment. The chiropractor then carried out a procedure to address this, as a consequence of which, C said, their migraines largely disappeared.

C believed that the board ignored their concerns about neck and shoulder pain and said that had they been addressed when requested, they would have had a better quality of life.

The board’s view was that, throughout, C had been treated appropriately and in line with clinical guidance; x-rays were not normally recommended in migraine diagnosis and management and were not standard practice. They also said that clinicians were not trained in alternative procedures and were unable to recommend them.

We took independent clinical advice. We found that x-rays were not part of the normal practice in the diagnosis and management of migraine and that neck and shoulder pain can occur in 90% of patients with migraine. We also found that the alternative procedure given to C was not an approach offered by the NHS and that C had been treated in line with clinical best practice. We did not uphold the complaint.

Summary

C, an advocacy worker, complained to us on behalf of their client (A) about the care and treatment they received at Aberdeen Royal Infirmary. A had an autologous fascia sling procedure (where a strip of tissue from the abdomen is used to create a sling under the urethra) to treat stress urinary incontinence (where urine leaks out of the bladder when it is under pressure). A suffered two complications from the surgery; including a bladder injury and overactive bladder (needing to get to the toilet in a hurry or leaking urine before reaching the toilet). C complained that A was not properly informed about the risks during the consent process.

We took independent gynaecology (specialists in the female reproductive system) advice. We found that at A's clinic appointments, they were given appropriate information about the risks involved in the surgical options available. However, a significant period of time passed until A had the surgery. Moreover, surgery had not been A's first choice of treatment, and there was a change to the planned procedure. In the circumstances, we found that it was particularly important to have reiterated all the significant risks of surgery when A signed the consent form. However, we found no evidence that A was advised about the risk of overactive bladder, even though it is a common complication. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to appropriately inform them of the risk of overactive bladder. 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 consent process should follow national guidelines. As part of the consent process, information about the common and serious complications of surgery should be reiterated to the patient as close as possible to their surgery; and that information should then be clearly 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

Mrs C complained about the care and treatment provided to her late husband (Mr A). Mr A was admitted to hospital after he attended A&E complaining of abdominal pain with a background of hiatus hernia (where part of the stomach pushes up into the lower chest). Mr A had a nasogastric tube (where a tube is placed through the nose into the stomach) inserted to decompress the hiatus hernia, however on one occasion it fell out and a number attempts had to be made before it was reinserted. During this procedure, Mr A suffered a cardiac arrest and died.

Mrs C complained that the board inappropriately handled the insertion of his nasogastric tube and raised concerns that it may have caused Mr A's cardiac arrest. Mrs C also complained that insufficient attempts were made to resuscitate Mr A when he suffered cardiac arrest.

The board explained that nursing staff escalated the procedure for passing the nasogastric tube appropriately and that Mr A arrested before any further escalation could happen. The board also explained that Mr A’s cardiac rhythm was asystole (unshockable) therefore attempts to prolong resuscitation would be ineffective.

We took independent advice from a consultant general surgeon and from a consultant in acute medicine. We found that reasonable action was taken by the nursing staff in escalating the reinsertion of the nasogastric tube and there was no evidence that the procedure was inappropriately handled. We also found that the decision to stop resuscitation was made in consultation with the clinical staff present and the decision was reasonable in light of his additional conditions and the fact that his heart rhythm was asystole. Therefore, we did not uphold Mrs C's complaints.

Summary

Mr C complained about the care and treatment provided to his partner (Miss A) at Aberdeen Maternity Hospital. Mr C said that when Miss A attended a pre-caesarean section assessment, the doctor failed to identify that she was in the early stages of labour. Mr C also complained that the board failed to explain why their baby required antibiotics and a breathing tube after they were born, and that the board's handling of his complaint was unreasonable.

The board acknowledged that the doctor assessing Miss A had failed to carry out a full assessment. The board noted that the reasons why their baby required antibiotics and a breathing tube had been explained to Mr C by hospital staff and later in email correspondence. The board also carried out a comprehensive review of their handling of the complaint and identified areas for learning and improvement.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in the female reproductive system, pregnancy and childbirth). We accepted the board's view that the doctor failed to carry out a full of assessment of Miss A's condition when she attended for the pre-caesarean section appointment and that their handling of the complaint was unreasonable. We upheld these complaints on that basis and made further recommendations for learning and improvement. We concluded that there was reasonable evidence it had been explained to Mr C why his baby required antibiotics and a breathing tube at the time of the event and later in email correspondence. Therefore, we did not uphold this aspect of the complaint.

Recommendations

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

• The board should have a guideline in place for the management of patients attending the pre-caesarean section clinic. This should include standard questions to ask all patients such as about presence of vaginal bleeding, fetal movements, as well as contractions and leaking fluid vaginally.
• The board should have guidelines in place about the turnover time for issuing letters following debrief meetings.
• The board should have in place template letters which can be used when inviting patients for debrief meetings that make the purpose of the meeting explicit.

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 treatment which they received at the Golden Jubilee National Hospital. C had undergone a total right hip joint replacement but post operatively reported problems with right foot drop and loss of sensation in the right foot and leg. C was put on medication and referred to physiotherapy but still remained in pain with loss of sensation. C felt that something must have gone wrong during the surgery.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that there was no indication from the clinical records that complications had been encountered during C’s surgery in that the surgery was completed within normal timescales and that blood loss was within expected levels. It was possible that the sciatic nerve (nerve in the lower back area) could have been inadvertently damaged during the surgical procedure but there was no documentation to support such a view.

While we did not uphold the complaint, we noted concerns about the standard of the record-keeping regarding the brevity of the actual operation notes and whether sufficient discussions about C’s high body mass index (BMI, a measure for estimating human body fat) level, which would increase risks of any surgery, were discussed with them prior to surgery. The concerns were highlighted as feedback to the hospital who have already amended their procedures in an effort to improve learning.

Summary

C complained about the care and treatment they received regarding a fractured collarbone. C was scheduled to have surgery but on the day of the surgery a decision was made to cancel on the basis that C’s collarbone had healed. C complained about the decision to cancel the surgery and that a decision was not made to proceed with surgery at an earlier date.

We took independent advice from an orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that it was reasonable for the board to allow for six months of conservative (non-operative) management and to cancel the surgery following an x-ray which showed the fracture had joined together.

However, we found that it was unreasonable not to mention or discuss operative intervention and its associated risks at earlier clinic appointments. This is because patients should be informed of all treatment options including that of no treatment in accordance with the General Medical Council’s guidance on consent. We also found that it was unreasonable for one of the clinic letters to state that the x-rays showed hypertrophic (healing tissue has formed but the bone fractures have not joined) non-union. We noted that the x-rays actually showed a delayed union (when a fracture takes longer than usual to heal) because approximately four months had passed since C’s injury at that point. We also found that the decision to proceed with surgical intervention was unreasonable given that the x-rays showed delayed union, rather than hypertrophic non-union and there was no evidence that the clinician had discussed C’s case with the consultant. In light of the above, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not discussing operative intervention and its associated risks at their clinic appointments, and that the decision to proceed with surgical intervention was made when the x-rays showed delayed union rather than hypertrophic non-union, and while the clinician had not discussed C’s case with the consultant. 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:

• Decisions to proceed with surgery for clavicle fractures should be based on an accurate assessment of the patient including any available radiograph. Changes in a patient’s management plan from a consultant’s decision should be discussed with the consultant and documented.
• Patients should be informed of all treatment options, including that of no treatment and these discussions should be 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’s sibling (A) attended the practice with constipation and blood in their urine. C was referred to the local health board’s urology department (specialists in the male and female urinary tract, and the male reproductive organs) where they were diagnosed with pedunculated fibroids (benign (non-cancerous) growths in the uterus). This diagnosis was later found to be inaccurate and the growths were found to be cancerous. C complained that the practice failed to provide reasonable treatment to A when they attended the practice in response to their symptoms.

We took independent advice from a GP. We considered that the actions and investigations carried out by the practice were reasonable at each appointment, based on the information available at the time. A was referred to appropriate specialities and prescribed reasonable medication in response to their symptoms and the diagnosis made by urology. We did not uphold the complaint.

Summary

C complained to the practice about their failure to diagnose that they were at risk of suffering a heart attack when they attended the practice on two occasions. The GPs had diagnosed a chest infection; however, C’s condition deteriorated and they were admitted to hospital where it was discovered they had suffered a heart attack. C felt that the GPs should have diagnosed their heart condition sooner and that if they had then their heart would not have been so damaged.

We took independent advice from a GP. We found that the GPs involved in C’s care carried out appropriate assessments and that the symptoms which C presented with were not indicative of cardiac problems. We did not uphold the complaint.

Summary

C complained about the care and treatment they received from the board. C received a positive bowel screening result and attended a screening clinic shortly after. A colonoscopy (an exam used to detect changes or abnormalities in the large intestine (colon) and rectum) was arranged but was unsuccessful. C later underwent a successful colonoscopy which identified a rectal polyp (a small cell clump that grows within your body).

C’s polyp was initially considered to be benign (not harmful). They were referred for an endoscopic ultrasound (EUS) scan in another NHS board area. This identified that C had type two rectal cancer. C complained about what they considered to be a misdiagnosis by the board. They also complained about delays in the board carrying out a successful colonoscopy and arranging for an EUS to be carried out.

We took independent advice from a general and colorectal surgeon (a general surgeon who specialises in conditions in the colon, rectum or anus). In respect of the colonoscopy, we noted that there was a delay of around 24 weeks from C’s positive bowel screening until a successful colonoscopy was carried out. Although the delay was not wholly down to the board, we considered this length of time to be unreasonable. We noted that C was effectively placed at the back of the queue each time an appointment was not successful. We concluded that the board should have done more to progress C’s case following the failed colonoscopy. As such, we upheld this aspect of the complaint.

C’s second complaint was that the board unreasonably failed to diagnose that they had cancer following tests. We concluded that the board treated C’s polyp as being suspicious of cancer from the outset. However, we identified clear delays within the treatment pathway, which meant C’s cancer was not identified until later. This meant that cancer was either present during earlier tests, or developed in the months leading up to a later test. We concluded that the overall timescale could have been reduced significantly had the board reviewed C’s treatment options earlier. We upheld this aspect of the complaint.

Finally, C complained about there being a delay in the board arranging for an EUS to be carried out. We identified that the delay was partly due to the other board that the referral was made to. However, we noted that the referral was made with no apparent follow-up for more than two months. There was then a further two-month delay after the other board responded to say an EUS would be arranged urgently. We concluded that more could have been done to follow up on the referral made to the other board. In addition to this, we concluded that more could have been done in terms of looking at the overall waiting time experienced by C, given that the EUS was not essential. In light of this, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable delay in carrying out a successful colonoscopy; for the unreasonable delay in the treatment pathway that contributed to a delay in C’s cancer diagnosis; and for contributing towards there being an unreasonable delay in an endoscopic ultrasound being carried out, given this was a non-essential procedure. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

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

• If a referral to another board is required for a procedure such as an endoscopic ultrasound, this should be followed up appropriately. Consideration should be given to whether the benefits of making a referral to another board for a procedure such as an endoscopic ultrasound outweighs the risks caused by the delay in treatment resulting from this.
• A successful colonoscopy should be carried out within a reasonable timescale after a patient receives a positive bowel screening test result.
• If a patient fails to attend a colonoscopy, or the procedure cannot be completed, there should be a reasonable and patient-centred policy for rescheduling appointments.
• The pathway for diagnosing rectal cancer in a patient should be progressed within a reasonable timeframe. Consideration should be given to the timescales involved in managing complex polyps.

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 admitted to Stratheden Hospital following an overdose. C’s complaint is in relation to the care and treatment provided during this admission. C said they were left without medication and discharged without a proper follow-up plan.

The board acknowledged that medications were not available when they should have been. They said this was because C’s prescriptions needed to be ordered from the pharmacy and were not stocked on the ward. They said that a senior charge nurse had reminded staff to review prescriptions to ensure they are ordered in time. The board said they provided C with appropriate information about support services.

We took independent advice from a consultant psychiatrist. We noted that it was accepted that there was a delay with providing C with their medication. However, we found that the overall management of C’s condition was reasonable, with effective communication between staff and C documented throughout. As such, we did not uphold this complaint.