Health

  • Report no:
    201901343
  • Date:
    August 2020
  • Body:
    Highland NHS Board
  • Sector:
    Health

Ms C complained about the care and treatment her late father (Mr A) received at Raigmore Hospital after he died unexpectedly following elective knee surgery. Ms C also complained about Highland NHS Board's investigation of her complaint.

The Board's investigation of Ms C's complaint did not identify any failings in Mr A's care. We took independent advice from a consultant trauma and orthopaedic surgeon. We found that Mr A's symptoms prior to discharge were not appropriately acted on. Had they been, there is a possibility that other specialities could have been called in to assess and assist. However, we could not say whether this would have affected Mr A's outcome. We concluded that Mr A's postoperative care and treatment was of an unreasonable standard and upheld the complaint.

In terms of the consent process for Mr A's surgery, we were also critical that there was no record to demonstrate that all the specific recognised risks of a total knee replacement surgery were covered sufficiently during a clinic consultation. We concluded that this is contrary to national guidance on consent and was unreasonable.

We also found that the Board's investigation and response to Ms C's complaint contained inaccurate information; did not reasonably address all the concerns Ms C raised; and did not reasonably identify and address the failings in Mr A's care. The letter concentrated mainly on the opinion as to the cause of Mr A's death rather than systematically addressing the points Ms C had written in her complaints form. We concluded that the response to Ms C's complaint was not compliant with the NHS Complaints Handling Procedure (NHS CHP) because the investigation and response should have been more comprehensive, clearer and easier to understand. We upheld the complaint.

 

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Ms C:

Complaint number

What we found

What the organisation should do

What we need to see
(a)

There was an unreasonable failure to act upon Mr A's acute kidney injury and episodes of vomiting;

there was an unreasonable failure to demonstrate that all the recognised risks of total knee replacement surgery were covered sufficiently during the consultation on 30 January 2018; and

the Board's investigation and response to Ms C's complaint contained inaccurate information; did not reasonably address all the concerns Ms C raised; and did not reasonably identify and address the failings in Mr A's care

 

Apologise to Ms C and the family for failing to:

  • act upon Mr A's acute kidney injury and episodes of vomiting;
  • demonstrate that all the recognised risks of total knee replacement surgery had been fully explained to Mr A; and
  • provide accurate information in their complaint response to Ms C, address all the concerns Ms C raised, and identify and address the failings in Mr A's care

 

 

A copy or record of the apology.

By: 16 September 2020

 

We are asking the Board to improve the way they do things:

Complaint number

What we found

Outcome needed

What we need to see
(a)

The fluid balance chart was discontinued despite there being a significant fluid imbalance and an acute kidney injury having been identified;

the acute kidney injury was not acted upon (no intravenous infusion was given and no repeat blood testing carried out); and

no physical examination was performed prior to discharge

 

 

Patients with acute kidney injury should have their symptoms acted on and managed in line with relevant standards and guidance, where appropriate

Evidence that:

  • these findings have been shared with all relevant staff involved in Mr A's care in a supportive manner that encourages learning (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions); and
  • there is a standard operating procedure for the management of acute kidney injury and ensure it is included in junior doctor induction.

By: 11 November 2020

 

 
(a) The orthopaedic team did not seek assistance regarding the acute kidney injury from other specialities Patients should receive appropriate medical review for their symptoms

Evidence to:

  • demonstrate that these findings have been shared with the surgical staff involved in Mr A's care in a supportive manner that encourages learning (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions); and
  • demonstrate how junior doctors are supported on the surgical ward.

By: 11 November 2020
(a) There was an unreasonable failure to demonstrate that all the recognised risks of total knee replacement surgery were covered sufficiently during the consultation on 30 January 2018 Patients should be fully advised of all material risks of total knee replacement surgery and the discussion should be clearly recorded, in accordance with the Royal College of Surgeons standard

Evidence that:

  • surgical staff undertaking total knee replacement surgery have been reminded of the requirement to obtain informed consent in line with relevant standards and guidance; and
  • the consent form has been reviewed to ensure there is a section on the template to clearly capture material risks of the proposed procedure.

The SPSO thematic report on informed consent may assist in encouraging learning for staff in this area:

https://www.spso.org.uk/thematicreports

By: 11 November 2020

We are asking the Board to improve their complaints handling:

Complaint number

What we found

Outcome needed

What we need to see
(b)

The Board's investigation and response to Ms C's complaint contained inaccurate information; did not reasonably address all the concerns Ms C raised; and did not reasonably identify and address the failings in Mr A's care

The Board's complaint handling and governance systems should ensure that complaints are investigated and responded to in accordance with the NHS CHP. They should ensure that failings (and good practice) are identified; and that learning from complaints is used to drive service development and improvement

Evidence that:

  • these findings have been shared with complaint handling staff (both clinical and non-clinical) in a supportive manner that encourages learning (e.g. a record of a meeting with staff; or feedback given at one-toone sessions); and
  • the Board have reviewed why its own investigation into the complaint did not identify or acknowledge all the failings highlighted here and any learning they have identified.

By: 11 November 2020

Feedback

Points to note 

As well as the recommendation above to ensure there is a standard operating procedure for the management of acute kidney injury and to include this in junior doctor induction, the Board may wish to consider the placement of ward posters informing others about the issue.

Related reading

  • Report no:
    201806286
  • Date:
    August 2020
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health

Mr C complained about the care and treatment that he received from Greater Glasgow & Clyde NHS - Acute Services Division (the Board) after he sustained a navicular fracture to his left foot (a fracture of the navicular bone on the top of the midfoot). Mr C also complained that the Board failed to respond reasonably to his complaint.

In March 2017, Mr C attended the Emergency Department (ED) of the Queen Elizabeth University Hospital, Glasgow (the Hospital). Mr C was assessed by a junior doctor and found to have pain on touching some of the bones in his foot. An xray was ordered, which the junior doctor interpreted as showing an un-displaced fracture (a fracture where the bone fragments do not separate) of one of the metatarsal bones (the 'forefoot' bones linking the toes to the middle part of the foot). Mr C was given a walking boot, advice and discharged. Two days later, the x-ray was reported by a radiologist as showing no acute joint or bony injury.

At the start of May 2017, Mr C attended again at the ED following a referral from the GP out-of-hours service as his foot was swollen and he was still in pain. Further xrays were taken. Mr C was reviewed by the on call orthopaedic doctor. The doctor's diagnosis was that there was possibly a hairline fracture (a very fine fracture) of the fourth metatarsal. Mr C said he was advised nothing further could be done and was sent home. The following day, Mr C attended the orthopaedic out-patients department at the Hospital following a call asking him to attend. He was advised by an orthopaedic doctor that the third and fourth metatarsal were broken, in addition, the navicular bone was broken in three parts with a 5mm gap.

Subsequently, Mr C underwent surgery to address the fracture. However, he continued to experience problems with his foot. Mr C had a major limb amputation of the lower part of his left leg in October 2019.

We took independent advice from a consultant in emergency medicine, a consultant orthopaedic surgeon and a consultant radiologist.

We found that it was not unreasonable that the ED junior doctor did not identify Mr C's fracture in March 2017 as it was uncommon to see a patient present at the ED with a navicular fracture and a junior doctor will rarely see a patient present with this type of fracture and often not at all. In addition, the fracture was subtle on the x-ray. On account of this, the junior doctor who saw Mr C made an understandable, reasonable, mistake in not diagnosing that he had sustained a navicular fracture.

Notwithstanding this, Mr C's fracture should have been identified in the radiology report of the x-ray taken in March 2017 and although the fracture of the navicular on the x-ray was subtle; it was unreasonable that the radiologist did not report this fracture.

Mr C was diabetic. We found that the clinical history supplied on the request for the radiograph did not include this information. While we did not consider the failure to identify and include this information in Mr C's clinical history amounted to an unreasonable standard of treatment, had the information about Mr C's diabetes been supplied it may have further alerted the reporting radiologist to the possibility of a stress fracture.

We found that when Mr C re-attended the Hospital in May 2017 after being referred by the out-of-hours service, a further opportunity to identify the navicular fracture was missed.

In conclusion, we found that overall the Board failed to provide Mr C with a reasonable standard of care and treatment and that it was likely that the failure to identify Mr C's fracture in March 2017 had a detrimental impact on his outcome. In light of the failings identified, we upheld this aspect of Mr C's complaint. 

Finally, we found that the Board failed to handle Mr C's complaint reasonably and upheld this aspect of his complaint.

 

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Mr C:

Complaint number

What we found

What the organisation should do

What we need to see
(a) and (b)

The Board failed to provide Mr C with a reasonable standard of care and treatment

The Board's own complaint investigation did not identify or address the failings in Mr C's medical care

 

Apologise to Mr C for the failings in care and treatment identified in the report.

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets

 

 

A copy or record of the apology.

By: 19 September 2020

We are asking the Board to improve the way they do things:

Complaint number

What we found

What should change

What we need to see
(a)

The Board unreasonably failed to identify Mr C's navicular fracture

 

 

X-rays of patients attending hospital with a possible fracture should be appropriately reported.

Patients re-attending should have their presenting symptoms fully assessed and investigated

 

 

 

Evidence that the case has been discussed at a radiology Learning from Discrepancies meeting.

Evidence that the Board have reflected on the failings identified in Mr C's case and given consideration to any required changes to processes and guidance.

Evidence that these findings have been fed back to the relevant staff and managers in a supportive manner that encourages learning, including reference to what that learning is (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions).

By: 19 November 2020

We are asking the Board to improve their complaints handling:

Complaint number

What we found

Outcome needed

What we need to see
(b)

The Board's own complaint investigation did not identify or address the failings in Mr C's medical care

 

 

The Board's complaint handling monitoring and governance system should ensure that failings (and good practice) are identified; and that learning from complaints is used to drive service development and improvement.

 

 

 

 

Evidence that the Board have reviewed why its own investigation into this complaint did not identify or acknowledge the failings highlighted here, what learning they identified, and what action has been taken as a result.

My findings have been shared with relevant staff in a supportive way for reflection and learning.

By: 19 November 2020

 

 

 

Feedback

Points to note 
  • While it was not unreasonable that the junior doctor did not identify the navicular fracture when Mr C first attended the ED in March 2017, the Board may wish to consider raising awareness of a navicular fracture with junior doctors joining the ED on placement.
  • When a patient attends with a fracture at the ED, the Board may wish to give consideration to recording past clinical history as this can provide a potential alert for subsequent care and treatment.
  • Adviser 2 commented that the subsequent management of Mr C's case by the Board's consultant orthopaedic surgeon after the navicular fracture had been identified should be commended.

Related reading

  • Case ref:
    201902266
  • Date:
    July 2020
  • Body:
    Western Isles NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mr C, an advocate, complained on behalf of his client (Mr A) about the care and treatment Mr A received from the board when he attended hospital after his GP sent for an ambulance for him. The GP sent for an ambulance after a phone consultation with Mr A's wife, as they suspected that Mr A was having a stroke.

When Mr A was admitted to A&E, he was treated for fast atrial fibrillation (an irregular heart beat) and possible alcohol related issues. Mr A was discharged from the hospital on the day after he was admitted. However, he was admitted to hospital again the following day. A CT scan was carried out and this confirmed that Mr A had suffered a stroke.

Mr C said that medical staff within A&E did not act appropriately when Mr A was originally admitted to hospital and that medical staff unreasonably failed to investigate the possibility that Mr A had suffered a stroke, despite symptoms being identified in his admittance notes.

We took independent advice from an appropriately qualified adviser. We found that there was nothing contained in Mr A records when he was originally admitted that indicated he had suffered a stroke. Based on the evidence and Mr A's presentation, we concluded that it was reasonable for medical professionals to exclude a stroke at that time. However, we noted that Mr A symptoms were suggestive of a transient ischaemic attack (TIA; a stroke lasting for a shorter period, less than 24 hours). The records suggested appropriate consideration was not given to the possibility and symptoms of a TIA. If a TIA had been diagnosed, then the management of Mr A's atrial fibrillation may have been different. This may not have prevented Mr A's readmission or stroke, but could have changed the overall clinical management.

We concluded that medical professionals did not unreasonably fail to identify a stroke when Mr A was originally admitted. However, we concluded that the board did not give appropriate consideration to whether Mr A had suffered a TIA. In light of this, our view was that the board unreasonably failed to provide appropriate care and treatment to Mr A when he was originally admitted to hospital. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Mr A for failing to give appropriate consideration to the possibility he had suffered a TIA and as a result, did not include this as part of their atrial fibrillation workup and decision-making with respect to out-patient follow-up and anticoagulation. 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&E staff should be aware of the signs of a TIA and the links between TIAs and arterial fibrillation.

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.

Related reading

  • Case ref:
    201804428
  • Date:
    July 2020
  • Body:
    Western Isles NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

C complained about the mental health care and treatment provided by the board. They also complained about the board's communication in relation to their care and treatment.

C had been referred to psychiatry by their GP because of difficulties with anxiety and depression. C was seen by a psychiatrist who referred them for cognitive behavioural therapy (CBT) and discharged them from their clinic. C was re-referred to psychiatry urgently by their GP a few months later, following a deterioration in their mental health. C saw a psychiatrist three times and was referred for community psychiatric nurse (CPN) support because of the CBT waiting list and C's deteriorating mood state.

C saw a locum psychiatrist four times over a two-month period when C was experiencing a continued deterioration in their mental health. C then saw their original psychiatrist on another two occasions. C's mental health deteriorated further and they were admitted to a psychiatric unit.

We took independent advice from a mental health adviser, who noted from C's records that their clinical presentation was complex and multifaceted. We found that there had been a significant interruption in C's psychiatric out-patient care, with a period of 17 weeks elapsing between appointments. There was a further unplanned and unexplained gap of seven weeks between out-patient appointments. We considered these interruptions to be unreasonable, although we could not conclude with certainty that the interruption to continuity of out-patient care led to the deterioration in C's mental state and subsequent hospitalisation. Although we found that the care planning was reasonable, the significant unscheduled gaps between out-patient appointments were not reasonable, causing continuity of C's care to be disrupted. We therefore upheld this aspect of the complaint.

Overall, we considered that C had been appropriately enabled to participate in decision-making related to their care, but some failings in communication were noted. C did not receive an explanation for the issues with consultant cover which appear to have contributed to the gaps in their psychiatric out-patient care. On balance, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for failing to clarify precisely when their CBT referral was withdrawn; for the significant unscheduled interruptions to their out-patient psychiatric care; for failing to provide an explanation for the issues with consultant cover which contributed to the gaps in their psychiatric out-patient care; and for the instances of ineffective communication between the psychiatrist and CPN, including that which resulted in a delay in referring C to another service. 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:

  • When there are unscheduled interruptions to patient care, the patient needs to be informed of this. There also needs to be clear communication between staff when decisions are made in relation to patient care, such as onward referrals or requests for intervention by other disciplines. The timescales for the action and the person responsible for the action should be made clear, and the request should be appropriately followed up to ensure the action is taken. The board should feed the above back to staff in a supportive 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.

Related reading

  • Case ref:
    201810154
  • Date:
    July 2020
  • Body:
    Tayside NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    admission / discharge / transfer procedures

Summary

C is the parent of a teenaged adult (A). A was admitted to an acute admissions ward of a mental health unit as an informal patient. The following day, A contacted C from the ward. A told C that they were in possession of razor blades and intended to self-harm. C contacted the ward to advise them of this and ward staff obtained the razor blades from A. A day later, A contacted C and told C they had left the hospital. C contacted the ward and the police, and A was returned to the ward. A was transferred to another location shortly afterwards. C complained that A had not been properly searched or reasonably assessed on their first arrival at the ward. The board told C that the routine risk assessment at admission had shown no indication A was at risk of absconding, and that this had led to the decision not to lock the ward door. They also said that a check of A's belongings when they were admitted had led to razor blades being taken from A's possession. C was dissatisfied with the board's response and brought their complaint to us.

We took independent advice from a mental health nurse. We found that A had not been properly searched upon their arrival, that it was unreasonable that the board had not carried out a medical, nursing or joint assessment on the day of A's admission and that the standard of assessment and care-planning at the point of admission fell significantly below professional expectations. We upheld C's complaint.

C also complained that the board unreasonably failed to call C, as they had promised, following C reporting A was in possession of razor blades and intended to self-harm. We found that the available written evidence and staff recollection did not support C's recollection that they had been promised someone would call them back. Therefore, we did not uphold C's complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to A that they were not properly searched or reasonably assessed upon their arrival at the ward. The apology should meet the standards set out inthe SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

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

  • Medical/nursing assessments should be carried out and clearly documented as part of the admission process, and each patient has a documented initial care plan based upon the information gathered during the admission assessment process.
  • The belongings of patients assessed as being at imminent risk of harm to self or others are checked for the presence of harmful objects or substances.

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.

Related reading

  • Case ref:
    201809165
  • Date:
    July 2020
  • Body:
    Tayside NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mr C sustained a serious pelvic injury with internal bleeding following a road traffic accident and was admitted to Ninewells Hospital where he underwent surgery to repair the internal bleed and his fractured pelvis. Mr C suffered a further internal bleed and complained that there was a delay in identifying this bleed. Mr C also complained that the physiotherapy input he received following his surgery was unreasonable and may have caused his fracture to move; and that he was provided with inappropriate pain relief and his respiratory rate was not monitored properly.

The board considered that Mr C was monitored appropriately and that any delay in identifying the internal bleed was due to the fact that the CT scan was occupied by another patient. The board also considered that the physiotherapy input and pain relief provided were reasonable.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system), a physiotherapist and a general physician . We found that Mr C was appropriately reviewed and monitored and that there was no unreasonable delay in identifying the internal bleed. We also considered that the pain relief provided was appropriate and Mr C's respiratory rate remained stable. We did not uphold these complaints. However, with regards to the physiotherapy input, we found the standard of record-keeping to be poor and there was a failure to establish a treatment plan with agreed goals. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Mr C for failing to obtain all relevant information about him prior to beginning treatment and failing to establish a treatment plan with agreed goals. 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:

  • Physiotherapy records should meet the minimum documentation standards and the quality of records should be audited regularly.
  • The physiotherapist should reflect on their handling of this case and discuss their learning from it in a supportive manner with their line manager.

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.

Related reading

  • Case ref:
    201807031
  • Date:
    July 2020
  • Body:
    A Medical Practice in the Tayside NHS Board area
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Ms C complained to us about the care and treatment she received from her GP practice. She said that staff at the practice had not listened to her and had not provided reasonable care and treatment for her adhesions, diarrhoea and Myalgic Encephalomyelitis (ME; a long-term illness with a wide range of symptoms including extreme tiredness). She also said that the practice seemed fixated by her having depression and that she needed bereavement counselling or antidepressants without understanding her situation.

We took independent advice from a GP. We found that there was no evidence that staff had not listened to Ms C and that they had provided reasonable care and treatment in relation to her adhesions, diarrhoea and ME. It was also reasonable for the practice to offer Ms C bereavement counselling along with other treatment in relation to this. We considered that the care and treatment provided to Ms C was reasonable and we did not uphold the complaint.

Related reading

  • Case ref:
    201903349
  • Date:
    July 2020
  • Body:
    Scottish Ambulance Service
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    failure to send ambulance / delay in sending ambulance

Summary

Mr A fell at home and a 999 call was made to the Scottish Ambulance Service (SAS) to attend. The call was prioritised as an emergency response where an ambulance would be dispatched as soon as one became available. An ambulance arrived with Mr A approximately four hours after the initial call. Mr A was later diagnosed with a broken hip.

During Mr A's rehabilitation in hospital, there were concerns that he had sepsis. Staff at the hospital called for an ambulance and requested an emergency response to transfer Mr A to another hospital for treatment. The ambulance arrived over two hours after the initial request.

Mr A's daughter (Mrs C) complained that the time taken for an ambulance to attend on both occasions was unreasonable and that Mr A's condition, on both occasions, should have resulted in an emergency response.

We took independent advice from an appropriately qualified adviser. We found that on each occasion the delay in an ambulance attending was not attributable to failings on the part of SAS assessing and prioritising the requests for an ambulance, or not appropriately allocating its resources. The delays were a result of a lack of availability of resources at the times in question and ambulances attending to higher priority calls. Whilst there was a significant delay in the ambulance attending to Mr A on each occasion, this was not attributable to failings on the part of SAS handling the calls. We did not uphold the complaint.

Related reading

  • Case ref:
    201809644
  • Date:
    July 2020
  • Body:
    Scottish Ambulance Service
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    failure to send ambulance / delay in sending ambulance

Summary

C complained that the Scottish Ambulance Service (SAS) failed to respond reasonably to the request for an emergency ambulance service for their child (A). C expressed concern about the overall time taken for A to be taken to hospital; which was approximately two hours from the original call being made requesting an emergency ambulance, to A arriving at hospital and being reviewed by a doctor. C also complained about how SAS responded to their complaint about that matter.

SAS upheld C's complaint on the basis of a longer wait than would have been expected for this category of call and offered an apology for that wait. They explained that this was a very busy time for the service but confirmed that a call audit had concluded that the call was handled very well and was of high compliance with their dispatch system.

We took independent advice from a paramedic. We found that there were concerns with SAS's response for an emergency ambulance, including:

The delay in elevating the response level which relied on the subjective opinion of a non-clinical call handler.

The lack of clinical advisor input into the call which could have negated the limitations of the system and possibly changed the level of acuity, and as such the response time and time taken for A to reach hospital.

The decision of the original ambulance crew to wait on the second responding crew to transport A.

Therefore, we upheld the complaint that SAS failed to respond reasonably to the request for an emergency ambulance to attend to A.

In relation to complaint handling, we found that SAS's response to C's complaint was appropriate. We also noted that their apology was in line with SPSO guidance. Therefore, we considered that SAS reasonably responded to C's complaint and we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for failing to respond reasonably to the request for an emergency ambulance to attend to A. 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:

  • Clinical advisors should be able to assess a patient's condition in line with current guidance - which provides that a clinical advisor's first point of contact should be at 45 minutes from the time of call within the yellow patient cohort. If a decision is made for this not to happen, the reasons for that decision should be clearly recorded.
  • Patients should be transported by ambulance using the appropriate harness.

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.

Related reading

  • Case ref:
    201908741
  • Date:
    July 2020
  • Body:
    Lothian NHS Board - Acute Division
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Ms C complained about the decision of staff at the Royal Hospital for Sick Children to assess that two referral letters from her child's (Child A) GP should be graded as routine rather than urgent. Child A had ankyloglossia (tongue-tie); this occurs where the strip of skin connecting the baby's tongue to the bottom of their mouth is shorter than usual which affected their ability to feed. As the board had added Child A to the routine waiting list, Ms C paid for the procedure to be completed on a private basis, and Child A immediately improved their feeding ability. Ms C believed that the GP referral letters should have been graded as urgent which would have allowed the procedure to be carried out sooner.

We took independent advice from a consultant paediatrician (consultant specialising in the medical care of children). We found that as Child A was able to feed using a bottle and was gaining weight, there was no need to classify the referral letters as urgent; this was in line with board policy. We did not uphold the complaint.

Related reading

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