Health

Summary

C complained that the board failed to carry out further tests when they became aware of the fact that their partner (A) had polyhydramnios (excess amniotic fluid) during pregnancy before giving birth to their baby (B). B was diagnosed with Noonan Syndrome (a genetic disorder that causes a wide range of features, such as heart abnormalities and unusual facial features) after birth. C considered that, if the board had carried out further tests, this may have led to the detection of Noonan Syndrome prior to the birth of B.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in the female reproductive system, pregnancy and childbirth). We found that the board's staff followed recognised practices when carrying out ultrasound scans and assessing the unborn child. During the 30th week of A's pregnancy, polyhydramnios was first raised as an issue. At that time it was a mild case and no abnormalities were identified with the foetus. By the 36th week of A's pregnancy, polyhydramnios had increased to a moderate case. We found that, whilst polyhydramnios is a feature of Noonan Syndrome, it can be caused by a number of other factors, and no other features of Noonan Syndrome were present. We found that there was no indication for an amniocentesis (a test offered during pregnancy to check if the baby has a genetic or chromosomal condition) to be carried out. If an amniocentesis had been offered, Noonan Syndrome would not have been identified, unless a specific test for this had been carried out. We did not uphold this complaint.

Summary

Mrs C complained that the board failed to deal with her complaint in a reasonable way. Mrs C made a complaint and received an acknowledgement but did not hear anything back for seven months. Mrs C asked for an explanation about the delay in keeping her informed and when the health board expected to be in a position to respond to the complaint. In all emails, Mrs C asked to be contacted by email. The health board responded the following month by letter saying that the matters raised were not new (as Mrs C had made several complaints previously) and they were handling the complaint under their unacceptable actions procedure.

In reaching our decision, we did not reach a judgement on whether the issues raised were new, but considered whether the health board handled the complaint in a reasonable way and whether their actions were in line with their unacceptable actions procedure.

During our investigation, the health board acknowledged their response to Mrs C was insufficiently clear about why they had determined that no further response to the complaint was required and that there was an unacceptable delay in responding to her complaint. Moreover, whilst we appreciated the health board did not email because of concerns about security, we considered that as long as complainants are made aware of any data protection concerns when receiving confidential information by email, then staff should respect a complainant's preferred method of contact. In addition, we found that staff should have signposted Mrs C to this office in their response in line with the NHS Model Complaints Handling Procedure (MCHP). Furthermore, there was no evidence that the health board complied with their unacceptable actions procedure in a number of respects. Overall, we found that the health board did not deal with Mrs C or her complaint in line with their procedure and we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to deal with her complaint in a reasonable way. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets.

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

• Complaints should be dealt with in line with the MCHP and, where appropriate, the board's unacceptable actions procedure. The MCHP and guidance can be found here: www.spso.org.uk/the-model-complaints-handling-procedures.

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 partner (A) following A's admission to University Hospital Hairmyres with drowsiness. There was an indication that A may have taken too much of their prescribed medication at home. C raised concerns that a period of deterioration during A's admission was due to poor care.

We took independent advice from an appropriately qualified adviser. We considered that A's deterioration was related to infection, and were unable to identify anything to suggest that their deterioration was due to poor care. We did not uphold this aspect of the complaint.

C complained that their concerns about A's deterioration were ignored, and that when they asked to speak to medical staff, this was not arranged. The board noted that C had been given the telephone number of the consultant's secretary, and that two doctors were on the ward during the day on weekdays and were available to speak to patients and relatives. We considered that nursing staff should have arranged for the ward doctors to speak to C, rather than providing a number to make an appointment with the consultant. We considered that this would have been simpler, quicker and more effective. We upheld this aspect of the complaint.

C also expressed concern about the arrangements in place for A's medication on discharge, including that they were not given a dosette box to assist them in managing the medication at home. We noted that there was concern that A's medication may have caused the symptoms which led to their admission, and as such they considered that the discharge medication should have received more care and attention. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for not giving more care and attention to A's discharge medication. 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:

• Care and attention should be given to arrangements for discharge medication, especially where there is evidence of a patient having had previous problems taking (or relatives having had problems administering) the correct medication.

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 there was an unreasonable delay in providing their parent (A) with a diagnosis of pancreatic cancer.

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) and a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines). We found that radiology unreasonably failed to detect and report pancreatic cancer from a scan taken five months prior to diagnosis and that there was an unreasonable failure to hold a multi-disciplinary team meeting between radiology and gastroenterology with imaging. We also found that there was an unreasonable delay in investigating the cause of A's pancreatic insufficiency as it would have triggered further imaging. We considered that earlier detection may have improved A's quality of life because they would have had a management plan for palliative care sooner. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for the delay in diagnosing A's pancreatic cancer at the three points detailed in the decision. 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:

• Regular multidisciplinary meetings should be arranged where difficult cases are discussed with imaging and clinical information available.
• The board should encourage the use of multiplanar reformatting facility (involves the process of converting data from an imaging modality acquired in a certain plane, usually axial, into another plane).
• The board should ensure all organs are assessed for CT reporting.
• To ensure radiological errors are reviewed with all reporting radiologists and radiographers to facilitate shared learning.
• To view this case as a learning opportunity that a lower threshold for suspicion of pancreatic cancer should be adopted by clinicians.

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 child (Child A). Mrs C felt that Child A was denied access to NHS doctors with experience in paediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS - a neurological and psychiatric condition in which symptoms are brought on or worsened by infection). She also felt that the board had unreasonably refused to treat Child A with antibiotics and had instead suggested mental health treatment as an alternative. Mrs C had requested that Child A be referred to specialist clinicians in England and felt that the board had unreasonably denied this request.

We took independent advice from a paediatrician. We found that there was evidence that the board were engaged with the medical literature on PANDAS and used this to inform their decision not to offer antibiotic treatment. We considered this to be a reasonable position and concluded that the board provided appropriate care and treatment in this respect. We also considered that the board's approach to obtaining second opinions and referring Child A to alternative clinicians was reasonable. We did not uphold this aspect of Mrs C's complaint.

Mrs C also complained about the board's communication with her. We found that there was evidence in the records of timely and appropriate communication, and there was no evidence of unfair treatment. We did not uphold this aspect of Mrs C's complaint. However, we did identify that there were issues with the board's handling of Mrs C's complaint, as there was a delay in issuing a response and the response did not address all the issues Mrs C had raised. Therefore we made a recommendation under section 16G of the SPSO Act 2002, which requires the Ombudsman to monitor and promote best practice in relation to complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the delay in issuing the formal response to her complaint, and for the failure to address the issues she had raised in the formal response to her complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Complaint responses should be full and timely.

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

Mr C complained about the treatment the board provided to him following his surgery for Dupuytren's Contracture (a condition in which one or more fingers become permanently bent in a flexed position). Mr C complained that he had suffered an infection post-operatively which was not appropriately treated.

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 the board had provided a reasonable standard of treatment to Mr C. He was seen regularly after the operation and no concerns were recorded by clinical staff that Mr C was suffering from a post-operative infection that was clinically significant (required treatment). Therefore, we did not uphold Mr C's complaint.

Summary

Ms C complained to us about the care and treatment provided to her late partner (Mr A) by Raigmore Hospital during an admission. Mr A was assessed and a crisis plan was agreed; Mr A was then discharged home, but soon after he died. Ms C complained that the board unreasonably discharged her partner home. She also raised concerns about the significant adverse event review (SAER) carried out by the board into Mr A's care and treatment.

We took independent advice from a mental health nurse and from a consultant psychiatrist (a medical practitioner who specialises in the diagnosis and treatment of mental illness). We found that the board carried out an appropriate and systemic risk assessment. We found that a coherent short-term crisis plan was agreed with Mr A, until he could engage with his local mental health services. We found that the decision to discharge Mr A home was reasonable. We did not uphold this aspect of Ms C's complaint.

We found that the board's SAER process and report was reasonable; and it identified appropriate learning. However, we noted that when Ms C complained to the board, they said that they would address her concerns through the SAER. In the circumstances and given the time it took to complete the SAER, we considered that the board should have kept Ms C updated more regularly on its progress. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to keep her appropriately updated. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets

In relation to complaints handling, we recommended:

• If the board decides to address a complaint through their SAER, they should then keep the complainant appropriately and regularly updated on its progress.

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

Miss C complained about the care and treatment her late mother (Mrs A) received at Raigmore Hospital after she was admitted with symptoms of bleeding from her stoma (an artificial opening made into a hollow organ, especially one on the surface of the body leading to the gut or trachea). Mrs A died around three weeks later following surgery to revise the stoma (resected ileostomy). Miss C raised concerns that the surgery was unnecessary and Mrs A had not properly consented to it; that the nursing care was poor (in terms of wound management, personal care, repositioning Mrs A and cables that had tied down her hands); and that the board did not handle Miss C's concerns through the NHS Model Complaints Handling Procedure (MCHP) appropriately.

We took independent advice from a consultant general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We considered that the decision to operate was reasonable on the basis that Mrs A had multiple admissions in the period immediately prior to this admission and required blood transfusion. In addition, Mrs A had undergone appropriate investigation to identify the source of gastrointestinal blood loss and that the pathology report of the resected ileostomy had confirmed that it was the source of bleeding. In addition, we were of the view that although Mrs A had experienced a rare complication of the surgery, there was no evidence that it had fallen below a reasonable standard. However, we found that there was insufficient evidence to show that any of the recognised risks of the surgery had been discussed with Mrs A. We considered this unreasonable and not in accordance with guidance. Therefore, we upheld this aspect of Miss C's complaint. We noted that the board's investigation had accepted that the documentation regarding communication was of an unreasonable standard and that the staff involved had reflected on their practice for learning and improvement. The board also took steps to amend the surgery consent form to ensure that the recognised risks of surgery are clearly captured.

In terms of nursing care, we found this to be reasonable and appropriate. We did not uphold this aspect of Miss C's complaint.

In relation to complaint handling, we found that the board should have summarised the issues for investigation and checked whether Miss C wanted to provide any further information before they issued their response to the complaint. Therefore, we upheld this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the failings identified in terms of the documentation of communication; the surgery consent process; and the handling of her 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 surgical staff understand their responsibilities in ensuring important events and communications with the patient or supporter is recorded; and involving patient supporters in decisions about treatment in accordance with the Good Surgical Practice guidance.
• Ensure the current standards of consent are followed as outlined by the Royal College of Surgeons.

In relation to complaints handling, we recommended:

• Ensure complaints are handled in line with the NHS MCHP: www.spso.org.uk/the-model-complaints-handling-procedures

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 client (A) who was admitted to the Royal Alexandra Hospital after fainting at home. A CT scan showed that A had suffered a fractured bone in their neck. A was initially fitted with a collar but C complained that this did not fit well and caused A severe pain and discomfort, to the extent that A's neck injury became worse. Due to A's ongoing pain, a further CT scan was carried out which confirmed that the fracture had displaced (not lined up) slightly. A was referred to the spinal unit at another hospital and was fitted with an alternative form of brace. C complained that A should have been referred to the spinal unit from the outset.

We took independent advice from an orthopaedic consultant (a doctor specialising in the treatment of diseases and injuries of the musculoskeletal system). We considered that the initial investigations and treatment were reasonable. We found evidence that the fitting of the collar was checked by staff. We also considered that the subsequent change to an alternative brace was reasonable, and there was no indication for an earlier referral to the spinal unit. However, we were critical of a delay in reporting the second CT scan. This was an urgent scan which should have been reported within days, but it was not reported for three weeks. This delay did not cause A harm, but it did prolong their pain and discomfort. The treatment of A's injury was otherwise of a good standard and, on balance, we did not uphold this complaint.

Summary

C complained that the care and treatment they received from the board when they were admitted to Inverclyde Royal Hospital with severe abdominal pain was not reasonable. C raised issues regarding lack of a laparoscopy (a type of surgical procedure that allows a surgeon to access the inside of the abdomen and pelvis without having to make large incisions in the skin being performed), and delays in receiving a CT scan and antibiotic therapy. C had concerns that these issues contributed to the major surgery they ultimately underwent for suspected appendicitis (a painful swelling of the appendix).

We took independent advice from a general surgeon. We found that while a laparoscopy would have been helpful in diagnosing C's condition, it was not unreasonable that the board did not perform one in C's case. However, we found that a CT scan should have been performed earlier in C's admission, particularly when the decision was made not to perform a laparoscopy. We further found that it was unreasonable not to provide antibiotic therapy earlier in C's admission, given their presentation with features of infection. We found it was likely that, had the board performed a CT scan earlier, C would have undergone surgery earlier or received antibiotic therapy sooner, and this would have altered the clinical course with earlier and more minor surgery. As a result, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in their care and treatment. 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 managed so that they receive treatment and scanning based on their clinical presentation at the appropriate time.

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.