Health

Summary

C complained about a globe perforation (small hole in the eyeball) which occurred during retrobulbar injection (an anaesthetic injection given into the eye) for a left trabeculectomy (a surgical operation to lower pressure inside the eye). C reported the injection being extremely painful and felt that this should have alerted the doctor to the perforation.

We took independent advice from an ophthalmologist (a specialist in the branch of medicine concerned with the study and treatment of disorders and diseases of the eye). We found that there is a debate as to whether retrobulbar injections have been outmoded by alternative methods of local anaesthetic. Though we did not consider it a failing that the board used this method of anaesthetic, we suggested that they may wish to reflect upon whether the methods of local anaesthesia should be reviewed in light of the outcome of this case.

We also found that the globe perforation that C experienced should have been suspected at an earlier point. We found that whilst the pain C experienced did not indicate a definite perforation, this should have raised suspicion of perforation. We also considered that had the perforation not been suspected/identified at the time of the injection, it should have been the following day when C experienced a leakage of blood in the eye. We upheld C's complaint on this basis.

The board had already discussed the case with doctors involved in C's care, presented the case at a teaching session, and discussed the case at a clinical governance meeting. However, we made further recommendations on the basis that the board had not identified that the perforation could have been suspected at an earlier point.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that they did not suspect/identify the globe perforation 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 a patient experiences marked pain at the time of retrobulbar injection; or vitreous haemorrhage following retrobulbar injection, clinicians should be alert to the possibility of a globe perforation.

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 to us about the care and treatment he received when he attended the out-of-hours service at Stobhill Hospital. Mr C had undergone a shoulder operation at the hospital on the previous day and was discharged that afternoon. He returned to the hospital on the following day, as he was in pain. He said that he had also been unable to urinate. He saw a doctor but complained that they did not examine him or take a sample and he was told to go home and make an appointment to see his GP if he did not feel better within two days. Mr C said that he was in pain for the next two days and vomited blood. When he saw his GP, he was rushed to hospital and a catheter was fitted, which drained two litres of fluid.

We took independent advice from a GP. We found that the examinations and the assessments carried out when Mr C attended the out-of-hours service had been reasonable. Urinary retention can develop over time and there was no evidence that Mr C had urinary retention when he presented at the out-of-hours service. We considered that the care and treatment provided to Mr C had been reasonable and we did not uphold the complaint.

Summary

C, an advocate, complained on behalf of their client (A). A's appendix was removed after they suffered from acute appendicitis. After the operation A continued to experience pain and had multiple admissions to the Queen Elizabeth University Hospital over a period of several months. A was unhappy with the treatment provided by the board in response to their symptoms.

We took independent advice from a general anaesthetist experienced in acute pain services and from a general and colorectal consultant (a surgeon who specialises in conditions in the colon, rectum or anus). We found that the board provided reasonable treatment to A. There were elements of the management of A's symptoms of pain which could have been better, with chronic pain considered earlier once A's infection had resolved. However overall, the board's response to A's symptoms of pain and rectal bleeding were reasonable with reasonable investigations and treatment carried out. Therefore, we did not uphold this complaint.

Summary

C complained on behalf of their spouse (A). A had a history of metastatic cancer (cancer which has spread to another part of the body). A attended their GP with a sudden on-set headache and was advised to attend the Glasgow Royal Infirmary (GRI). A arrived at GRI as an emergency attendance and was admitted for investigation. Scans were carried out which revealed that A had an intracranial metastasis (a malignant growth that had spread to the brain from a tumour in another organ). C complained that there was an unreasonable delay in the scans being carried out. C also complained that A had unreasonably been advised that surgery was not an option.

We took independent advice from a consultant in acute medicine and from a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques). We found that there had been an unreasonable delay in the first scan being carried out given A's history, current medications and symptoms. All relevant information was not provided to the radiologist to determine the priority of the scan and, when the scan was not carried out as planned, the board failed to query this with the radiology department when it had not occurred as scheduled. We upheld this aspect of C's complaint.

In relation to the second complaint there was little information available to confirm exactly what was said between the board, C and A regarding the discussion that surgery was not an option for A. We found, based on the information available, that the board had reasonably informed A that curative surgery was not an option in relation to their intracranial metastasis. Therefore, we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to carry out A's scans in a reasonable timescale. 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 relevant information should be provided to the radiology department when requesting a CT scan.
• Patients presenting with a headache and taking anticoagulant medication should receive appropriate investigations to identify whether an urgent scan is needed.
• The board should carry out scans in the timeframe agreed.

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

Ms C was referred by her GP to the board's Assisted Conception Service (ACS). At her appointment with ACS months later, she was told that it was too late to proceed with screening/referral to the Assisted Reproductive (ART) Clinic tertiary centre, as the waiting time for an appointment at the ART is five to six months, by which time she would be over the age limit (the upper limit to be eligible for in vitro fertilisation (IVF, a process of fertilisation where an egg is combined with sperm outside the body) treatment on the NHS). Ms C complained that, according to the information on the board's website, she should have been eligible for NHS fertility treatment.

We took independent advice from a consultant gynaecologist (a doctor who specialises in the female reproductive system) and from a GP. We found that the information on the board's website regarding timescales for referral for fertility treatment had originally been incorrect, as it stated that a patient need only be referred prior to their 42nd birthday, as opposed to needing to be screened before their 42nd birthday. However, we found that the board had amended this information in order to ensure it was accurate. Whilst we welcomed this, we were concerned that the incorrect information was not noted by the board until drawn to their attention by our office.

We considered that, whilst changes had been made, the information on the website was still unclear as it did not explain the steps involved in screening, and the waiting times involved in these steps. We also found that the board's position regarding how they communicate this information to GPs is not in line with current primary care practice. We upheld this aspect of Ms C's complaint.

With regard to Ms C's complaint that she was unreasonably denied fertility treatment, we found that Ms C did not meet the criteria, and therefore it was reasonable to deny her fertility treatment. Therefore, we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C that the information on their website regarding timescales for referral for IVF is unclear. 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 information available to patients and GPs should make clear the referral pathway, screening process, and timescales involved in these steps, are explained clearly; including how long before the patients 42nd birthday they may need to be referred to complete the screening process in 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.

Summary

Ms C complained about the care and treatment provided to her husband (Mr A) at the Royal Alexandra Hospital when he attended A&E with a headache, nausea, resolved left sided weakness and a facial droop. Mr A underwent medical review and scanning and was admitted into hospital. The following morning Mr A's condition appeared to deteriorate and following a further scan he was found to have had a type of stroke.

We took advice from a consultant in acute medicine, and a consultant radiologist (a specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found that the care and treatment provided to Mr A had been reasonable, with timely assessments and investigations. We did not uphold this aspect of Ms C's complaint.

Ms C also complained about the communication with Mr A's family, particularly when he deteriorated. The board had reviewed Mr A's care and acknowledged that there were failings in communication. Whilst the board had already shared the findings of their investigation widely, we made a further recommendation on this point. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A and Mrs C for the failure to communicate reasonably with Mr A's family. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Communication with families/next of kin should be part of the response to a deteriorating patient.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Ms C, an advocacy worker, complained to us on behalf her client (Mr A) about the care and treatment Mr A received at a consultation when he disclosed details of his mental ill health. Ms C said that the GP did not make eye contact with Mr A and rushed through the consultation. Ms C also complained that Mr A was subsequently removed from the practice list after they submitted a complaint.

We took independent advice from a GP. We were unable to comment on the amount of eye contact made during the consultation as there was no evidence in relation to this. We noted, however, that the GP had stated that they would try to learn from this. The practice had also stated that the consultation took longer than the ten minutes allocated. We found that the practice had a lot of history available for Mr A and the decision to decline referral to psychiatric services was based on their knowledge of Mr A and his medical history. We considered that the care and treatment provided to Mr A at the consultation was reasonable and we did not uphold this aspect of the complaint.

In relation to the complaint that the practice unreasonably removed Mr A from their list, we found that the practice should have issued a warning letter to Mr A before removing him from their list. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

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

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

When C became a patient of the practice their 'as required' medication was reduced and stopped. Within a couple of years C moved to another GP practice. They complained to the practice that the decision to reduce and stop their medication had been unreasonable, that they had not been reasonably monitored following the ending of these prescriptions and that the practice had failed to provide their notes to the new practice within a reasonable timescale. The practice responded that they felt the decision to stop medication had been reasonable and that C had received good and safe clinical care. They also stated that, while one specific summary part of C's notes had not been provided to the new practice initially, this had been corrected as soon as they had been made aware of it, and they had apologised for it.

We took independent advice from a GP adviser. We found that the decision to stop the medication was reasonable in principle given C's circumstances and the possible long-term effects of their use; that the withdrawal was carried out in line with applicable guidance; that a reasonable level of follow-up was provided; and that the practice's explanation that the failure to provide part of C's medical record to the new practice had been reasonable. We did not uphold C's complaints.

Summary

Mr C complained about the care and treatment his late brother (Mr A) received at Queen Elizabeth University Hospital (QEUH). Mr A had a number of complex medical conditions; he had previously undergone liver transplantation and suffered a brain aneurysm. Mr A was admitted to QEUH for treatment associated with an unusual resistant form of cytomegalovirus (CMV, a virus). Mr A's health deteriorated during his admission and he died in hospital.

Mr C complained that the board failed to provide Mr A with reasonable clinical care and treatment. Mr C also raised concerns that there was a lack of reasonable communication with him and his family about Mr A's care and treatment.

We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines); a consultant in critical care and anaesthesia with experience in transplant services and a senior nurse.

We found that there were aspects of Mr A's care and treatment that were reasonable. In particular, in relation to the management of Mr A's blood pressure and the fall in his platelets. When Mr A's condition deteriorated, there was no unreasonable delay in escalating him to the intensive care unit (ICU). In relation to the staff caring for Mr A, there was clear evidence of regular reviews and consultation and liaison between a large number of different specialists at QEUH and the transplant unit.

However, we identified the following failings in Mr A's clinical care and treatment:

For a period of time it was not noticed that there was an unintentional co-adminstration of two medications. While, on balance, any impact was limited and was not a significant contribution to Mr A's eventual outcome, this should not have occurred and was an omission in care. This was acknowledged by the board and appropriate action was taken.

We found that there was a lack of recording of Mr A's titres (level of virus). In addition, insufficient consideration was given to carrying out further investigations in order to confirm a diagnosis of Mr A having posterior reversible encephalopathy syndrome (PRES, a rare condition in which parts of the brain are affected by swelling) rather than CMV encephalitis as a possible alternative diagnosis.

Mr A had infected CMV that was known to be resistant to valganciclovir (antiviral medication) and the decision to restart Mr A on this medication was unreasonable. As this treatment was ineffectual, an alternative treatment should have been considered. Whilst it was wrong to use valganciclovir, on balance, taking account of the evidence any impact was limited and was not a significant contribution to Mr A's eventual outcome.

We found that communication with Mr A's family was reasonable while he was in ICU. However, prior to this communication with Mr A's family could have been better and their concerns about aspects of his care and treatment did not appear to have been reasonably addressed.

Mr C further complained that the board's investigation of and response to his complaint was inadequate. The board acknowledged that their complaint response letter was not issued within 20 working days in terms of the relevant guidance. Given the complexity of the complaint, we considered that the delay in providing a response was reasonable in the circumstances. However, we identified an error in the board's calculation of when the 20 day working period for providing a response to Mr C's complaint started. Following the issue of the board's response to the complaint, Mr C had contacted the board making further comment. We considered that the board should have informed Mr C when he could reasonably have expected to receive a response to his further correspondence and if there was going to be a delay in providing this. However, this had not happened.

We upheld all of Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and his family that insufficient consideration was given to carrying out further investigations in order to confirm a diagnosis of PRES; about the decision to restart valganciclovir and not to have considered an alternative treatment for resistant CMV; for the failure to record Mr A's titres; for the lack of reasonable communication with Mr C and his family about Mr A's care and treatment; and for the failings identified in complaint handling. 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 receive appropriate investigation prior to confirming a diagnosis of PRES. Decisions about medication should be reached after careful consideration of the effectiveness of the medication and potential side effects. There should be appropriate recording and monitoring of a patient's condition and this should be documented.
• Communicating significant news, especially bad news, to a patient and/or their family should be carried out in a clear and sensitive manner and without any unreasonable delay.

In relation to complaints handling, we recommended:

• Complaint responses should be accurate and in accordance with the board's Complaints Handling Procedure. The board should aim, whenever possible, to inform a complainant about when they should expect to receive a response to their communication and if there is going to be a delay in providing this.

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 attended the practice with a growth on their face. When after initially being prescribed antibiotics the growth remained, the practice referred C to the local NHS board's plastic surgery department as a routine referral. C contacted the practice some months later as the growth had enlarged and C was experiencing other symptoms. The referral was upgraded to urgent and C was seen by the plastic surgery department shortly after. C was subsequently diagnosed with a malignant tumour and underwent further treatment by the board after the diagnosis.

C complained to the practice about the treatment that they received. C said that if the malignant tumour had been diagnosed sooner, then the treatment to remove the tumour would have been less invasive and impactful on their appearance. The practice responded via the local NHS board. Dissatisfied with the response, C brought the complaint to our office.

We took independent advice from a GP. We found that the practice's working diagnosis of a sebaceous cyst (a common non-cancerous cyst of the skin) was reasonable, with appropriate treatment provided, initially with antibiotics and, when the cyst remained, with a referral to the local NHS board's plastic surgery department. We considered that the skin cancer had presented atypically, and it was therefore reasonable that the practice initially considered the lesion to be a benign lesion, rather than an atypically presenting cancerous lesion. When it was reported that the lesion had grown and C was experiencing other symptoms, the practice reasonably escalated C's referral to urgent. We did not uphold the complaint.