Health

Summary

C complained about the care and treatment provided to them by the board when they presented with a suspected ectopic pregnancy (a pregnancy in which the fetus develops outside the uterus, typically in a fallopian tube). C’s main concern was that they were not scanned on arrival at the hospital as it was outwith scanning hours. C ultimately had surgery to remove the ectopic pregnancy and a fallopian (tubes along which eggs travel from the ovaries to the uterus). C was concerned that had a scan occurred at an earlier point, it may have resulted in a better outcome.

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 C was triaged and transferred within a reasonable timescale on arrival to the hospital and that their management was appropriate in the context of being seen outwith the working hours of the early pregnancy assessment scanning service. We did not uphold C’s complaint.

Summary

Mrs C, an advice and support worker, complained to the board on behalf of her client (Mr A) about treatment which Mr A received at Raigmore Hospital. Mr A was diagnosed with bowel cancer following a positive bowel screen and endoscopy. Mr A underwent surgery to remove the tumour. Initially, keyhole surgery was planned but during the procedure the surgeon was unable to locate the tumour and the operation was changed to full surgery. Mr A developed an infection in his abdomen following the surgery and had to be taken back to theatre. Mr A remained in hospital for a number of weeks and was subsequently discharged home with a stoma and wound bag. Mr A wished to know what went wrong with his care and treatment.

We took independent advice from a consultant surgeon. We found that there were no concerns about the standard of treatment which Mr A received. Initially, it was appropriate to consider keyhole surgery based on the scan results but when the surgery commenced it was noticed that the tumour was in a different position. It was then appropriate to proceed to open surgery, which was completed appropriately with no issues. However, Mr A subsequently developed an infection, which is recognised complication of surgery rather than an indication that the surgery was not performed appropriately. We did not uphold the complaint.

Summary

After injuring her finger, Mrs C was referred to the orthopaedic department. Her injury was reviewed on a number of occasions before being diagnosed as dislocated. A procedure was carried out to put the joint back into place. The pain in Mrs C’s finger did not improve, despite cast treatment and physiotherapy, so she was referred back to the orthopaedic department. After a further review, it became apparent that Mrs C had developed a complex regional pain syndrome (CRPS) in her right hand.

Mrs C complained to the board that there was an unreasonable delay in identifying that her finger was dislocated. She considered that the procedure to correct the dislocation should have happened sooner and, if it had, she would not have developed CRPS. She remained unhappy with the board’s response so brought her complaint to us.

We took independent advice from an orthopaedic consultant (a doctor specialising in the treatment of diseases and injuries of the musculoskeletal system). We found that there were a number of opportunities in Mrs C’s case for her dislocated finger to be identified earlier. We concluded that there was an unreasonable delay in reporting of the x-rays taken of her hand. We upheld Mrs C's complaint.

Recommendations

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

• The board should ensure timely reporting of images to avoid delays as identified in Mrs C’s case in future.

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 that the practice failed to provide his late wife (Mrs A) with reasonable care and treatment.

Mrs A had presented to the practice several times with severe back pain over a ten month period. Mrs A was told to self refer for physiotherapy. Mrs A subsequently went to A&E due to the pain she was suffering in her back. Mrs A was diagnosed with renal cancer which had spread to her spinal column and brain. Mrs A died from her illness.

We took independent advice from a GP and a nurse. We found that although the practice doctors had been involved in prescribing painkillers and muscle relaxants to Mrs A, her back pain management and treatment plan was effectively being managed by the physiotherapy service who are independent practitioners. It was reasonable for a GP to expect that if a physiotherapist was concerned about deteriorating or urgent clinical signs in a patient that they would arrange appropriate hospital assessment or a scan. Mrs A had at no stage when she saw the practice doctors presented with red flag signs (indicators that a more serious problem may be developing/underlying) to suggest cancer. As such, the care provided by the practice doctors was reasonable.

We found that with regard to Mrs A’s consultations with the advanced nurse practitioner, she had presented with potential red flag signs including unexplained weight loss. While Mrs A’s presenting symptoms were very atypical of renal cancer, it had not appeared that cancer had been considered given Mrs A had shown potential red flag symptoms and signs. We found that these red flag symptoms and signs had not been acted upon. Therefore, we upheld the complaint.

We acknowledged that the practice in their complaint response to Mrs A and to this office accepted there were failings by the practice. They said they had learnt from Mrs A's case and we acknowledged the action the practice had taken to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to identify that Mrs A had presented with red flag symptoms and signs for cancer at consultations with the Advanced Nurse Practitioner and to take appropriate action. 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:

• Relevant staff should be aware of the local and national guidelines on presentations with acute and chronic back pain and ensure they are up-to-date with current best local and national practice, including red flag presentations.

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 provided to their parent (A) while a patient at Glasgow Royal Infirmary. A was admitted with a large bowel obstruction. C complained about the delay in a stent procedure being carried out (a procedure where a small tube is inserted to keep a passageway open).

We took independent advice from a consultant colorectal (a surgeon who specialises in conditions in the colon, rectum or anus) and general surgeon. We found that there was an unreasonable delay in the stenting procedure being carried out and a combination of the delays and A’s deteriorating health, with rising C-reactive protein (CRP - an inflammatory marker) and National Early Warning Scores (NEWS a system that records key observations about the health of a patient with the higher the score the greater the clinical risk), was not reasonably responded to. When the stent procedure was delayed there was a lack of alertness to A’s deterioration and the management plan was not reviewed. We found that the board could have been better in assessing A’s fluid balance, noting their continued deterioration over a several day period, and attention to the worsening CRP. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their sibling for failing to provide reasonable treatment to A during their admission and for the inaccuracies in the complaint response. 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:

• Fluid balance recording and management in critically ill patients should be reasonably managed.
• The board staff should actively review trends in NEWS scores in critically ill patients.
• When management plans are in place and patients are awaiting treatment, there needs to be ongoing review of the management plan.
• Treatment for bowel obstruction should be appropriately prioritised in the board's hospital.
• Stenting in bowel obstructions should be appropriately prioritised, based on the clinical picture and have a limit of no longer than 48 hours from admission, when there is evidence of obstruction in an emergency setting.

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 diagnosed with diabetes (a condition that causes a person's blood sugar level to become too high) and they were given treatment with insulin (a hormone made in your pancreas. It helps your body use glucose (sugar) for energy. In type 1 diabetes your pancreas no longer makes insulin, so you have to inject it to control your blood glucose levels) and had follow-up care with the diabetes clinic. After several months, C decided to stop injecting insulin as they felt that this caused pain in their legs. C complained that the board had misdiagnosed them, that insulin had caused pain in their legs, and that their concerns were not taken seriously by staff at the diabetes clinic.

We took independent advice from a consultant diabetologist (doctor specialising in the diagnosis and treatment of diabetes). We found that once the diagnosis of diabetes had been made, insulin was the correct treatment and was reasonable. However, we found that it appeared that there had been a missed opportunity to diagnose the diabetes several months earlier and this was unreasonable. On this basis, we upheld C’s complaint. We also found that the pain C had experienced could have been caused by the administration of insulin. Whilst we were clear that insulin was the correct treatment for C, we suggested that the board could have acknowledged the possibility of the insulin contributing to C’s pain.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to diagnose them with diabetes at an earlier point. 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 low blood sugars indicate a diagnosis of diabetes, this should be followed up.

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 board has been unable to provide them with dentures that fit and function. They said that their ill-fitting and ill-functioning dentures have had a significant impact on them and affected many aspects of their life. C felt that staff have not listened to their concerns or treated them appropriately. C also advised that they consider that they require dental implant treatment to assist with denture use.

The board said that C has had intensive support over a number of years regarding their denture use and has exhausted treatment options and assistance within the secondary care setting. They confirmed that C’s concerns have been reviewed by consultants and implants are not an essential requirement of being able to retain dentures. The denture technique which has been used should make adaption to wearing dentures easier for C and whilst it is recognised that this can be challenging initially, persistence is required for success. Furthermore, the board advised that C does not meet the criteria for dental implant treatment.

We took independent advice from a dental adviser. We found that C’s dental records show that consultants at the board had made a lot of effort in providing several sets of dentures to C and there were no other treatment options that the board should have considered or offered. Therefore, it was reasonable for the board to assert that they have exhausted treatment options and assistance in relation to this matter within the secondary care setting. As such, we did not uphold the complaint.

However, we recognised that there had been some concerns regarding communication and provided feedback to the board for future learning and improvement.

Summary

Mr C, an advocacy worker, complained to us on behalf of his client (Mrs B) about the care and treatment the board provided to Mrs B's son (Mr A). Mr A was a patient at a clinic within the board area, when he experienced what appeared to be a seizure. Mr C complained about how the board responded to this, and in particular, that they delayed in taking action and failed to recognise the seriousness of Mr A's condition.

We took independent advice from both an adviser in general medicine and in psychiatry. We found that Mr A's clinical presentation did not suggest it was an emergency situation or that he was at serious risk. We found that the duty doctor assessed Mr A within a reasonable timeframe and managed his condition appropriately. We did not uphold the complaint.

Summary

Ms C, a support and advocacy worker, complained on behalf of her client (Ms A) who was treated for an abscess in her breast which failed to heal. Subsequently, a tissue sample was sent for tests and Ms A was diagnosed with breast cancer. Ms A considers that there was an unreasonable failure to consider cancer as a possible diagnosis at an earlier stage and that this contributed to the delay in providing diagnosis and treatment. Ms A also considers that concerns she raised about a possible cancer diagnosis were not taken seriously.

We took independent advice from an appropriately qualified doctor. We found that, although it was not reasonable to expect a cancer diagnosis to be considered sooner, excised tissue from two operations should have been sent for examination, which may have facilitated earlier diagnosis. On balance, we upheld this aspect of the complaint.

In relation to communication, we considered that the clinical records evidenced reasonable communication. Therefore, we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A for failing to send tissue removed during surgical procedures for histological examination, and the likely delay in diagnosis this resulted in. 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:

• All tissue removed during a surgical procedure should be sent for histological examination, unless it is considered not necessary by the operating surgeon and such justification is documented in the patient’s 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 about the care and treatment provided to them by the board. C presented to hospital with abdominal pain and bleeding and was told that they were either experiencing a miscarriage or an ectopic pregnancy (a pregnancy in which the foetus develops outside the uterus, typically in a fallopian tube). C was told to return for a scan in several days.

C complained that the board did not offer a scan at the time of presentation, keep them in for observation or discuss treatment options. C felt that, as a result of the delay in scanning, their condition deteriorated and they had fewer treatment options when they attended another hospital several days later.

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 it was reasonable that C was not given a scan on presentation as this was outwith scanning hours; and that it was reasonable that they were not kept in for observation or to discuss treatment options. However, we found that C should have been offered a scan within 24 hours of presenting at the hospital, or failing this, as soon as scanning services were available, as opposed to being given the next routine scan appointment. On this basis, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to offer them a scan in a timely 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:

• Patients requiring emergency scanning should have this carried out in a timely manner.

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.